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M ECHANICAL.I NSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hocty affim uoda pcrulty of pcrjury thar I m qmpt from thc ContnctoB' Licre law for thc following |ten.(S6.7031.5 Buins and Profeion Codc): Any City or County which rcquire a pcmh to snsruct, altc, improve danolish or cpair uy structuq prbr to its isumcc. also rcquiG the ryplicmt for such Fmit to filc s sign€d $atmdt that hc or shc b licdEcd puMt to thc prcvisioro of thc Cotrtrrtor's Liccnscd krv (Chaptr 9. Commacing with Sction 7000 of Division 3 of thc Buins md Prcfcsioro Codc) or that hc or shc is qmpt thqc&on ud thc bcis for thc allcgcd aoption. Ary violatiotr of Selioo 7031.5 by atry applicanr for I pcrmit subjcts thc rpplicant to a civil pqalty of rct morc the fivc hundrcd dollm ($500). --1. as owner ofthe propcrty. or my employees with wages as their sole compensation. rvilldo the work and the stnrture is not intended or offered for sale (Sec.7M4. Business and Professions Code: The Contractor's License law does not apply to an owner of the properly rvho builds or improves theron. and who does such rvork himself or herself or through his or her own employees. provided that such imp,rovonents are not intcnded or offiered for sale. I[, horverrer. the building or improvement is sold wilhin one year of completion. sale). the Orvner Builder will have the burdcn of proving that he or she did not build or improve the for the purpose of -1. as owner of the property. am exclusively contracting rvith licensed conlraclos lo construct the and Proftssion Code: The Contractor's License Law does not apply to an orvner of property who 7044. Business thereon. and who contracts for such projects rvith a Contracto(s)to the _l am exempt under Section_ llo to.-:E-? -l-l I hereby affirrn under pcnalty of perjury one of the follos'ing declarations: -- I have zutd s'ill rnaintain a Certificate of Conserrt to Self-lnsure fitrr workers' conrpensation. as provided for by Section 3700 of the l.atxrr ('ode. for the perfornrance of the u'ork for rvhich the pennit ls issued. _.1 have and rvill maintain rvorkers' compensation insurance. as required by Section 3700 of the Labor Code. for the perf<rrmance of the u'ork for u'hich this pennit is issued. My u'orkers' compensation insurance carricr and prlicy number are: l'rrlic) Ntttttlrt't'. l'r,1.i1('s' _-l certify that in the perforrnance of the rvork for s'hich this perrnit is issued. I shall not onploy any nlilnlrcr so as to become subject to the rvorkers' compensation larvs of California. and agree that if I should become rvorkef,s' compensation provisions of Section 3700 of the Labor Code. I shall. forthrvith comply with those WARNING: f;ailure to secure rvorkers' compensation and shall pc'rraltics an<l civil fines up to one hundred thousand dollars to the cost as pr.zvided for the Section interest and ( DE(:l.ARATION I hcreby affinn uncler penalty of periury that I arn licensetl under provision of ('haptcr 9 (comrnencing s'ith Section 7000) of Division J of the Business and Professions Code. and nry license is in full ftrrce zur<l effe<t. License l.iccnse Nurnber: l)ntc:_ ('onlrRclor: CONS'I'RUC'I'ION LENDING AGEN(:Y I hercby alfirnr under pcnahy ofperjury that thse is a constnrction lcndirrg agency for the pcftrnnance oflhe rvork for $'hich lhis pmnit is issucd (Str. .1097. ('iv. ('.). l,ender's Name: Lender's Address: APPLICAN't DIiC I,ARA'tION I hocty affirrn untlcr perralty of per.iury one of the follou'ing declarat ions: Dcrnolition Perrnits-Astrstos Notificatiorr Federal Regulations ('f itle 40. I'ar1(r) _ Rerluired Lelterof Notification -l certify that the IUeralregulations regarding asbestos removalare not _l certi0 that I have read this the above to comply rvith all City and County orclinances and State Las's City and County to enter uFlon the above rnentioned property for Applicanl or Agent Pennitee narne and rs I )atr.' 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 ll Hood Grease Duct Fire Damper Openings lnstallation F. D. Drop Test Above Hard Lid Above T-Bar tt /I ,^aRough Mech.lllMlr0n llailkal 74W Final Test tl Meter Release I I tt /.A, FINAL l,+l % 170 lWYtt(d 5fr il^ Notes, Remarks, Etc.I l On ncr: Carrier: to this I w,