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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hacby affim undc penalty ofpcrjury lhar I m exmpl from the Contractors' License Law for thc following reirn (Se.7031.5 <br />Buincs and Profsion Code): Any City or Comty which rcquira a pa'mit to construct, altc, improvq dcmolish or repah my <br />strucluc, prior to its i$umce, slso requirs the applicut for such pemit to filc a sigtred siatmot that he or shc is liccns€d pwuAnt <br />to the prcvisions of th€ Contractor's Liccnsed Law (Chapt6 9, Comcncing rvith Sction 7000 of Division J of thc Buins md <br />l'rcfcssionsCode)orthathcorsheisexemptthscfromildthebssisfortheallcgcdexmption. AnyviolationofscctionT03l.5byo, <br />applicant for a pamit subjsts the applicill to a civil penalty of not more tha fivc hundrcd dollm ($500). <br />-1. <br />c oms ofthc Foperly. or my employe with wagc a their olc compsuation, will do the wrt md th€ struct@ is mt <br />immded or offqed for sa.lc (Se.7044. Bshs ad Profcssiom Codq The Con(raclor's Licmc Law doo not apply to m oma of <br />lhe prcpqty who buil& or imprcvG thren. md who doe such wo* himsclf or h6elf or through his or hfr om cmployeG. <br />provided that such improvmts re rct intdd€d or offdpd for elc. If, howrys. thc building or improvffit is rcB whhin onc )w <br />ofcompletion, the Ownq Builds will have thc htrdo ofproving lhat he or she did not build or imffove thc pmpqty for thc purporof <br />sde). <br />-1. <br />re orwr of thc propoly. m cxcluively contracling with licrucd contracton to coNtruct the plojct (56. 7044, BuitrN <br />and Profrssbn Codc: The Conlractor's Liccnse Law do6 not apply to e own6 ofpropsty who builds or imprcvB ths@n. <br />and who contracts for such prcjsts wilh a Cootmcto(s) licNd puEumt to the Contractor's Licose Law). <br />_l m excmpt ud6 Sstion_. B. & P.C. for this r6on. <br />WORI(ERSI COMPENSATION <br />DECI.ASAIIAN <br />I bqcby affm unds poa.lty of pcjury onc of thc following delratiom: <br />-l <br />have ad will mintain 8 Cenificate of Cocot to Sclf-lEure for workos' conrpeo$tiorl 6 providcd for by Setiotr 3700 of thc <br />tabor Codc, for the pofomucc of thc work for which thc pqmit is isued. <br />-l <br />have and will maiilain workers' compcmatiotr isuilcc, 6 rcquted by Setion 3700 of thc t bor Code. for the pqfomuce of <br />the work for which this pmil is i$ued. My workrs' compcnsalion imumce mia od policy numbo rc: <br />Policy L L3 ?-t -lq <br />-l <br />cediry that in the psformancc of the work for which this pmit is issued. I shall not mploy any pmon in any munq <br />rc o to beome subjml to thc work6' comp€nstion laws of Califomia ad agrc that if I should b.come subj(t to the <br />work6s'compsationprovisioroofSrction3T00oftheLaborCode,tshall,fonhwithcomplywiththo*prcvisioN.. <br />WARNING: Failure to scue workm' compruation covsage is unlawful. and shall subjcct an qnploys to sirninal pemhie md <br />civil finq up to one hu&d thoMd dollffi ($100.000). in addition lo the cosl of compemtioo. dmagcs 6 providcd for thc <br />S€tion 3076 of thc Labor Codc, int66t ad attorney's fG. <br />Drrq l-tq-lq <br />LICENSED CONTRACTOR <br />Drcr.{iLdrtoN <br />I hrcby aflim urdo paalty of pojury that I m licensed undo provisioo of Chaptg 9 (commocing with Sction 7000) of Division 3 <br />of the B6in6 ild Prcfessiorc Code, ad my licme is in full force ed cffet. <br />qlsqrtLiceroeNumber: <br />-'Lo <br />CONSTRUC'IION LF,NDTNG ACENCY <br />I hereby affirm under poalty of ps.jury that thqe is a conslruction lending agency for the pqfomance of the work for which this pwnit is <br />issued (Ss. 3097. Civ. C.). <br />Lender's Name <br />Lender's Addrs: _ <br />I hadry atrm undo penalty ofpo'jury ooe ofthe following dslilatioos: <br />Demolition Pmils-Asb6tos Notiflcation Fedqal R€gulations (Title 40, Pilt6) <br />-Required <br />Letts of Notification <br />-l <br />cqtiry that thc lidqal rcgulatioN rcgsding sbstos rmoval [e not applicable to this prcjcct. <br />$ "rtity t a t torc rad this applicatiotr ed statc thal thc abovc infomation is conrt. I agre to comply with 8ll City md Couty <br />ordimce md Stste laws rclding to building coostructioD, Ed hqeby authorize rcprffitaiivB of this Chy ed Couty to @tq upon thc <br />above mmtioncd propcny for <br />Applicant or Agmt <br />Pmit€nmc ^d <br />l-zx'tt <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openinqs <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rouqh Mech. <br />Fina! Test <br />Meter Release <br />F!NAL tr'Lo-2-o DaGPlaS <br />Notes, Remarks, Etc.