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APPROVALS DATE ID/SIG.COMMENTS Appliances Metal Fire Place Evaporative Cooler Furnace Compressor Misc. Equipment Duct Work Pre-lnsulation lnsulation Smoke Detectors lnstalled Rouqh Ductwork 18-ta Lc?-1 Vents Toilet Room / Clothes Dryer Residential Range Other Hood fype I Hood Type ll Hood Grease Duct Fire Damper Openinqs lnstallation F.D. Drop Test Above Hard Lid Above T-Bar Rough Mech.#IH Final Test Meter Release FINAL {-Ra)l?,€t< t )otlB ( z-t7 Notes, Remarks, Etc. _1, n oms of thc prop€rty. or my employe with wag6 s thcir sle compemation. will do the work md the struclue is not int@dol or offqcd for slc (56.7044, Busin* md hof*ioN Code: The Contractor's Licme law do6 not apply to o owns of the propqty who builds or imprcrc thqorl. md who dm such rcrl himself or hmlf or thrcugh his or ha om mployc. providcd that such improv@ts m rct iolqdod or offqed for sle. lf, howryq. thc building or inFovcmt is sH within one )q ofcompleion, thc Owno Buildq will havc thc hrdq ofproving lhd hc or she did not build or imprcve the prcpqly br thc purpoe of salc). _1. o orvns of thc prcpety, m exclusivcly contracting with licGed contractoBto coNtruct the project (Sc. 7044. BBins md Proftsion Code: The Contractor's License Law do6 not apply to il ownq ofprop(rty who builds or improvc thsmn. and rvho contncls for such projsrs with I Contmcto(s) licmed pmwl to the Contractor's Licffi Law). I en e\crnpl under sccli(rn for this re6on. I hoeby aflim unde penalty ofpojury onc ofthe following _l havc md will maintain a Ccrtificatc of CoNot to Self-lNurc for workas' comproation, o provided for by Setion 3700 of thc Lrbor Codc, for thc pEfotlrucc of thc wort for which the psnit b issucd. _l have and will maintain rvorkos' comperoation iNurancc. a requircd by Sction 3700 of thc Labor Codc. for the pqfomuce of thc work for which thi! pflnil ir bsued. My workm' compwtion imurmcc cuiq od policy numbs se: c*:*,ZldeSl /U,o.kona l Tnsvrar<c- oo. poricyNumb': ? bOoO I s1o?lLrl ,,or*, llltltT -l ceniry thal in the pqfomance of the rvork for which this psmit is issued. I shall not m uto become subjet to the work6'comp$ation laws of Califomia and agree lhat if I otploy any pmon in any mmner should become subjat to thc work6' compcrution prcvisios of Setion 3700 of thc t bor Codq I shall, forthwith comply with thoe prcvisioru.. \ilARNING: Failure to suc worke' compcroation covoagc is unlawful, md shall subjct m oploye to qimioal pqdti€s ed civil fmo up to one hundrcd thoMd dollm ($100.000). in addition to thc cost of compemlion, daroge as provided for thc SBtion 3076 of thc l"rbor Codc hlq6t md sdtomey's fG. DI]CTltRA'I'ION I hueby aflim under psalty of pejury that I an liccnsed undo provision ofChapltr 9 (comnrencing rvith Selion 7000) of Division 3 of the Business and Profosions Code. od my licerse is in full forcc md eff(tl. Liccmc Drte: I hoeby affim undo penalty of pqjury thal th6e is a construction lending agocy for the pdfommcc of the work for which this p6mit is issued (Sc. 3097, Civ. C.). Lendq's Nmc: tgrder's Addre: AEPJ.ICANLDECI.ABAIION I hatby atrrn uctcr pcnalty of pajury onc of thc following dclamtioDs: Danolitioo PmitgAsb6tor Notificrrion Fed@l Rcgularione (Thlc 40. Put6) -Rcquirod trttq of Nolificalion _l cqtify thst the fedoal rcgulatiore regrding 6b6tos r@oval tre not applicablc to this project. -l cgliry that I havc @d this application od slatethat the above infomation is corst. I agre to comply with all City and County ordinoco ud Slatc kws rclating to building conslructio& ild hseby aulhorize reprGotalivG of lhis City ild CounIy ro at6 ufpn the above motioned pmpcny for iGpedion purpos6. Applicot or Agmt Pmnite nanc """, -Ifz*f 11 MECHANICAL-INSPECTOR RECORD ,O I Ir OWNER BUILDER DELCARATION I hocby affim unda pcnalty of po-jury thar I m cxcmpt ftam thc CootractoB' Licruc taw for thc following Buincs and Prof*ion Codc): Any City or Couty which rcqufs a pornh to constsct, alt6. improvc, danolish or structua prior to its irsumce. also rcquirc thc spplicet for such pcmit to filc a siSncd ststmat thar h€ or she b liccoscd Professions Code) or lhat hc or she is crcmpt thseftom md lhe beis for the alleged cxmption. applicant for a pmit subjets the applicant to a civil pcnalty of not morc thm five hundred dollus ($500). """,1lzwl11