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MECHANICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hercby affLm urder penally of pcrjury that I m cxcmpl from tlrc Contncto6' Lhcns lrw for thc followitrg rcasn (Sec.7031.5 <br />Business and Prcfession Code): Any City or County whhh rcquircs I ,f,mil to @nslrucl, allq, improw, demlish or EJEir any <br />6lruclurc, pdor to ils issume. also rcquircs thc rpplicant for such pcmil to lih o sigEd statcmnt thal he or dE is licnsd plruot <br />to thc pDvisions of the Contrctor's Liensd t w (Chaptcr 9, Comming vith Sfflion 7(m of Division 3 of the B$ircss and <br />ProfcssionsCodc)ortharheorsheisexemplthercfroma[dthcbcsisforlhcsllegcdcxcmption. AnyviolatiinofSsiionJo3l.5bysny <br />spplicant for s pcmit subjccls lhe spplicrnt to a civil penalty of not mrc than fivc hundrcd dollils ($500). <br />-1. <br />as owncr of the proFerty. or nry employces with wages as their solc compcnsation. willdo thc work and lhe structure Ls not <br />intended or ofFered for sale (Scr.7(X4. Busincss and hofcssions Codc: The Contractor's Liccnse Law does not apply lo nn owncr of <br />thc propcrty who builds or improves thercon. and who docs such work himself or hersclf or lhrough his or hcr own employces, <br />providcd that such improvenrcnls are not intendcd or offercd for salc. lf. howcver. thc building or irqrroverrcnl is sold within one year <br />of cornpletion. the Owner Builder will havc the burden of proving that hc or she did not build or improve thc propcrty for thc purynse of <br />sale). <br />-1. <br />as owner of the propcrty. am cxclusively contracting with licensed contrectors to conslruct the proict (Sec. 7W. Business <br />and ft,ofesshn Code: The Contractor's License Law docs not apply to an owner of progrcrty who builds or improvcs thcreon. <br />and who contracls for such proicts with a Contractor(s) licenscd pursuent to thc Contractor's License Law). <br />-lamcxcmptunderScction-.B.&P.C.forthisrcason.lhtr::( )n ner: <br />1VORKERS' CONI I'ENSA'I'ION <br />DIiCLARA'tI()N <br />I hcrcby affirrn under pcnalty of pcrjury one of thc following declarations: <br />-l <br />havc and will maintain a Certificatc of Consent to Self-lnsure for workers' compensation. as providcd for by Section 3700 of the <br />Labor Code. for the performance of thc work for which thc permit is issucd. <br />4 have and will maintain workcrs'compensation insurancc. as rcquired hy Scction 37fi) of thc Labor Code, for lhe grcrformance of <br />work pcnnil is My workers' compensation in.surance carricr and plicy numbcr are: <br />t <br />a <br />t <br />LPolicy <br />o <br />_l ccrtify that in the pcrformance of the work for which this pcrmit is issued. I shall nol ernploy any person in any manncr <br />so as to bccomc subject to thc workcrs'compensation laws of California. and agrec that if I should become subject to the <br />workers' compcnsation provisions of Section 3700 of thc Lahlr Code. I shall. forthwith cornply with thosc provisions.. <br />WARNING: Failurc to sccurc workcrs' comlrcnsation coverage is unlawful. and shall subjcct an cmploycr to criminal pcnaltics and <br />civil fincs up to onc hundred thousand dollars ($100.m0). in addition lo thc cost of conrpcnsation. damagcs as providcd for thc <br />alt()rncy's <br />I hcreby affirm under penalty of Jrerjury that I am liccnsed under provision of Chapter 9 (commerrcing with Section 7000) of Division 3 <br />of the Business and Professions Code, and my license is in full forcc and effect. <br />tLicensc <br />W <br />I hemby 8fftrm urtdcr pcndty of Frjury that thw k 8 @nstructhn lcnding agercy for the pcrfre of lhe uork for whbh this lEmil is <br />issued (S4. 3$t7, Civ. C.). <br />Lcndcr's Name: <br />lrndcr's Addrcss: <br />^ppl <br />,cAN,,rEcLA <br />I trrcby atlirm undcr pcnalty of pcrjury onc of thc following dcclarations: <br />Dcmolition Pernrits-Asbcstos Nolification Fedcral Rcgulations (Titlc 40. Parl6) <br />-Rccluircd <br />lrtter of Nolilication <br />-l <br />certify lhat thc fcdcralregulations rcgarding asbcstos rcmovalare not applicablc to this proict. <br />with all City and County <br />Applicant or Agcnt <br />? <br />Pcrrnitcc narrrc <br />and County lo entcr ufnn the <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />Insulation <br />Smoke Detectors lnstalled <br />Rough Ductwork <br />Vents <br />Toilet Room I Clothes Dryer <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type II Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test n <br />Meter Release IA <br />FINAL .-.9--h?O \./&+1tl <br />Notes, Remarks, Etc.\ \/ <br />) <br />,"::" -c'q"ru'i;li <br />intcrcsl <br />)r_tf,U,1 {Vr,,nf.,\NL <br />i,r\\?,St( <br />,,ru, 4\lLtill\){Wu,,(*nez