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M ECHANICAL-I NSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER I'ELCARATION I hwby affm undo poralty of pajury that I m qmpt ftom thc Conlractors' Liccnsc Law for thc following @tr (Se.7031.5 Buins urd Prcfsion Codc): Any Chy or County which rcquirc a po'rnit to @nstruct. altc. improvc dcmolish or rpair uy shuctuc Fior to its iswcc. also requic thc applicmt for such pcf,nit to 6le a signcd statmot thd hc or'shc b licmscd pu$ad to thc provisioN of lhc Contrsctor's Licenscd [:w (ChEpt6 9. Comcncing with Setioo 7000 of Division 3 of thc BNincs ild Prcfsions Code) or that hc or shc is qmpt thqeftom ud thc b8is for thc allegcd cxmption. Any violation of Sction 7d-l1.5 by any applicmt for a pomit subjcts thc applicmt to 8 civil pcmlty of not morc thil fivc hundrcd dotlars ($500). -1. as owner ofthe prop€rty. or my employees with wages as their sole compensalion. will do the work and the structure is not intended or offered for sale (Soc.7044. Business and Professions Code: The Contrac{or's License Law does not apply to an owner of the propcrty who builds or improve thereon" and who does such wort himself or hcrself or through his or her own employees. provided that such improvanents are not intcnded or offered for sah. t[, howel'er. tlrc building or improvement is sotd wilhin one ]car of complaiorL the Ourner Builder will have the hrden of proving tlrd he or she did not build or improve the property for the purposc of sale). -1. as owner of the property. am exclusively contracting with licensod contractors to construct the project (Sec. 7044. Business and ProfEssion Code: Thc Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projeds with a Contracto(s) licersed pursuant to the Contractor's Liccnse l-aw). -l am exempt undcr Section-. B. & P.C. for this reason. Owner:_ WORKERS' COMPENSATION DECLARATTON I hereby affrrm undcr penalty of perjury one of the following declarations: -l have urd will maintain a Ccrrificate of Conscnt to SelFlnsure for workers' conlpensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which the pcrmit is issued. -l have and 3700 of the Labor Code. for the po'formance of the rvork for and policy number are: -bl a) Policy -l certify that in the perforrnance of the rvork for which this permit is issued, I shall not employ any person in any manner so .ur to become subject to the work6s' compensation laws of California. and agree that if I should become subject to the workers' compcnsation p,rovisions of Section .1700 of the labor Code, I slull. forthwith comply with thosc provisions.. WARNTNG: Failure to secure workers' compensation coverage is unlawful. and shall subject an onployer to crirninal penalties and addition to the cost of compensation. damages as provided for thecivil fines up to one hundred thousand dollars ($in Section 3076 of the Labor Code.and so-v I ICI'NSED CONTITACTOR DECLARA"I'ION I hereby aflirrn under penalty of perjury that I arn licensed under provision of Chaptrr 9 (cornmencing rvith Section 7000) of Division -3 of the Business and Professions Code. and rrry license is in full force and effect. K,."*.z.El /\ CONSTRI.JCTION LENDINC AGT'NCY I hereby affinn unda pcnalty of ptrjury that thqe is a comtruction lflding agency for thc pafomoce of the work for which this 1mmit is issued (56. 3097. Civ. C.). Lender's Name: Lender's Address: ' ,rt tcANr ""('I hereb,y affrnn under penalty of perjury one of lhe follorving declarations: Denrolition Pernrits-Asbestos Notification Federal Regulations (Title 40. Par16) -Required Letter of Notification -l cdiry thd thc fodoal rqulaios rcgadiog asbetos mv.l m not applioblc to this prcirl. -l cgliry that t hflc ud this applicarion ad statc thst th€ sbovc infomdioD is con6t. I agrc to omply with all Chy md Couty ordiwB md Ststc L8w rclaing to building connrdioll ad hqcby suthoriE rcprsrt8tivB of this City ed Couty lo 6tE upoo thc '' Pennitee name l0- Appliances Metal Fire Place Evaporative Cooler Furnace Compressor Misc. Equipment Duct Work Pre-!nsulation Insulation Smoke Detectors lnstalled Rough Ductwork Vents Toilet Room / Clothes Dryer Residential Range Other Hood Type I Hood Type ll Hood Grease Duct Fire Damper Openings lnstallation F.D. Drop Test Above Hard Lid Above T-Bar Rough Mech. Final Test Meter Release FINAL /r{o-a (-ct5r '*l4r-)/7 Notes, Remarks, Etc. YI t Ereiro' ll (