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M ECHANICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUTLDER DETTARATION I hocby aflm unda pcrulty of pcjury thst I m cxmp from thc ConrrcloB' Licensc kw for thc following wn (Se.7031.5 Buinas md Profsion Codc): Atry City or County which rcquirc a pomit to construcl, altq, improvc, danolish oi rcpair uy struclurc. prior to its issuuca also requirc thc applicur for such psmit to file a signcd starmat that hc or shc b licoscd plmut to the provisioG of thc Contractor's Licnsd Law (Ch8pt6 9. Comcncing with Setion 7000 of Division 3 of thc BEins md Prcfcsiore Codc) or that hc or shc is cxmpt thacfrom md thc bris for thc allcgcd amflion. Any violation of Sction 7031.5 by mi applicantforapemitsubjctsthc applicattoacivilpemltyofnotmorethefivchundrcddollm(3500). -1, 0s owner of the property. or my employces with wages as their sole compqsstion, will do the work and the structtne is not intendcd or offcrcd for sale (Sec.7044, Business and hofessions Code: The Contractor's License Law does not apply to an owner of the propcrty who builds or improve theron md who does such wort himself or herself or through his or her own employees, provided that such improvanents ane not intendod or off€rod for sale. [[, howwer. the building or irnprovenrent is sold wilhin one y€ar of complaion, the Orvncr Buildcr will have the hrdcn of proving ttra he or she did not build or improve ttre pnoputy for the purposc of sale). -t, os owrrer ofthe propcrty, am exclusively contracling with licensed contractors to construct the project (Sec. 7044. Btniness and ProfEssion Code: The Contractor's License Law does not apply to an own€r of propcrty who builds or improves thcreon and who contracts for such projccts with a Contracto(s) licensed pumuant to the Contractor's License law). -l am cxcmpt under Section-. B. & P.C. for this reason. Date: Owner:_ WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: -l have and will maintain a Cqtificate of Consent to Self-lnsure for workers' contpensaliont as provided for by Section -1700 of the Labor Code, for the performance of the work for which thc pcrrnit is issued. -l have and will maintain workers' compensation insurance. as required by Section 3700 ofthe Labor Code, for the performance of the work fxryhich this permit is issned. My workers' compcrisation insurance caricr and policy number are: Policy lL-Ll>2o , -t certify that in the performance of the work for which this permit is issued. I shall not anploy any pcrson in any maluxf, so as to become subject to the work€rs'compensation laws of California, and agree that if I should become subject to the work€rs' compersation provisions of Section 3700 of the l-abor Code I shall. forthwilh comply with thosc provision3. WARNING: Failure to sccure workers' compensation is unlawful. and shall subject an anployer to oiminal pei'ralties and compensation. damages as provided for thecivil fines up to one hundred thousand dollars addition to cost of Section 3076 of the Labor Code, interest and ^ I ICENSED CON'I'RACTOR DECI ARA'IION t hereby allirm under penalty of perjury that I am licensed under provision of Chapter 9 (comrnencing rvith Section 7000) of Division -1 of the Business and Professions Code. and my license is in full force and effect.,B lofLicense Drte: Nurnber:&-a?b W I hcby alfm udo paulty of pCjury thar th@ b 8 ons(ruction knding agocy for thc pqfomc of thc worh br which this pqmit is i$ucd (Ss. 3097. Civ. C.). Lender's Name: Lender's Address: APPI IC ^ NT DFC] AILATION I hcdryatrnn under panalty of perjury one of the following declarations: Demolition Pcrmils-Asbestos Notification Federal Rcgulations (Title 40. Part6) -Required Letter of Notification _ -l certiff that the fderal regulations regarding asbestos removal are not applicable to this project. -l coti$, that I have read this application and state that rvith all City and County and County to enler upon theordinances and State Laws relating above mentioned property for Applicant or Agent Pennitee nilme Appliances Metal Fire Place Evaporative Cooler Furnace Compressor Misc. Equipment Duct Work Pre-lnsulation lnsulation Smoke Detectors lnstalled Rough Ductwork Vents Toilet Room / Clothes Dryer Residential Range Other Hood Type I Hood Type II Hood Grease Duct Fire Damper Openings lnstallation F.D. Drop Test Above Hard Lid Above T-Bar Rough Mech. Final Test Meter Release rl I AI --n,/ FINAL U p'{[)t)l),Wltht #"o[I Notes, Remarks, Etc. Slatz