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MECHANICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hoeby affirm undo peralty of prjury that I m exempt from the Contractors' License Law for the following re6on (Ss.703 1,5 Buinss md Profmion Code): Any City or County which require a pmit to construct. alto, improve, dmolish or repair my structue. prior to its isumce. also requirB the applicml for such pemit to file a signed statment that he or she is licmed pusudt to the provisios of the Contractor's Licensed law (Chapter 9, Commencing with Strtion 7000 of Division 3 of the Bwiness md Prof€ssions Code) or that he or she is exeinpt thqefrom md the basis for the alleged exmpliu. Any violation of Section 7031.5 by @y applicantforapmitsubjststhe appticanttoacivilpenaltyofnotrnorethilfivehundrltdouarp.{€600). _1. u omr of the properiy. or my mployffi with wag6 6 lheir sole compensation, rvill do the work md the structue is not intmded oroffsedforsale(S@.TM4,BuinesandProfessionsCoderTheContractor'sLicemelzwdoesnotapplytooownqof the prcperty who builds or improve thqon md who doe such rvork himself or hmelf or through his or her om mployes, provided that such improvments ile not intmded or offsed for sle. lf, howfls, the buildif,g or improvmmt is sold within one )@ ofcompletioe the Ownq Buildq will have the burdo ofproving that he or she did not build or imprcve the propety for the purpos of ule). _1, 6 offiq of the propsty. m exclusively contracling with licamed contractorsto construct the prcjtrt (56. 7044. Buins md Pmfesion Code: The Contractor's License Law do* not apply to m owns ofproperty who builds or improvB ths@n, and who contmcls for such prcjects with a Contracto(s) licemed purs@nt to the Contraclor's LiceNe Law). -l m exempt undq Sation-, B. & P.C. for this rruon. Drle:_ Owner: WORKERS' CO]\IPENSAI'ION DECLARATION I hereby affirm under penalty oIpojury one ofthe following declaralions: I hare ard rvill rnaintair a Certilicate ofConsent to Self-lnsure for workers' conrpensalion, m provided for by Section 3700 ofthe Labor Code, for lhe pqfonuance ofthe rvork ftrr rvhich lhe psmit is issued. _l have and will maintain workers' compensation insurance. d required by Section 3700 ofthe Labor Cod€. for the pqfomance of the work for which this pennit is issued. My workets' compeNation insurmce cmier md policy number oe: Policr Nurnber: E*pires, - _l certiry that in the poformance of the work for which this porrit is issued, I shall not employ any pmon in any rnano w ctobeomesubjecttothcwork6s'composationlawsofCalifomia.udagreethatiflshouldbecomesubjecttothe work6' compffiatioo ptovisioo of Seclion 3700 of the Labor Code. t shall, forthwith comply rvith thos provisiom.. WARNING: Failure to secue workqs' compemation coverage is unlawful. md shall an mployo to qiminal penaltis and civil lmes up to one hundred thoused dolltrs ln the dronages o provided for the Section 3076 Code. inttrest ild q. I hereby affirm under penalty ofpsjury that I iln licosd undfl provision 9 (commencing wilh Sfition 7000) of Division -l of the Busines ud Professiom Code. md my license is in full force md effect. +,,1License I hwby affrm undu penalty of ptrjury that issued (Src. 3097. Civ. C.). Lentler's Name - $a lending agency for the pefommce of the work for which this permit is Lender's Addras: - ATTIrcAXI.UECIABAIIQN I hoeby aflinn under penalty of perjury one ofthe following drclaations: Denrolition Permits-Asbestos Notification Federal Regulalio0s (Tille 40. Pd6) -Recluired Letter of Notification -l certirythat the federalregulations regrdirg cbetos rernovalae not applicable to this prcjtrt. that read this with all City and County md Coutyto entq upon theLaws relating to above propeny for Applicant Pmnitee Agmt state that the 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 Tvpe 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 V/?trlno 7b^^at/-zA ) Notes, Remarks, Etc a t I (I "^",uf 6lq