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APPROVALS Appliances Metal Fire Place Evaporative Cooler Furnace Compressor Misc. Equipment Duct Work Pre-Insulation Insulation Smoke Detectors Installed RouQh Ductwork Vents Toilet Room I Clothes Dryer Residential RanQe Other Hood Type I Hood Type II Hood Grease Duct Fire Damper OpeninQs Installation F.D. Drop Test Above Hard Lid Above T-Bar Rough Mech. Final Test Meter Release FINAL Notes, Remarks, Etc. MECHANICAL-INSPECTOR RECORD DATE ID/SIG. COMMENTS .--- I '-I'• _... V \../ OWNER BUILDER DELCA RATION , I hereby affirm uadcr penalty of perjury that I run exempt from the Contractors' License Law for the following reason (Sec.7.03 1.5 Business and Profession Code): Any City or Counly which requires a pcnnit 10 cons1n1c1. alter. impro ve. dcmpli sh or repair any structure, prior to its issuance, also requires the applicant for such pennit to fil e a signed statement that he or she is licensed pursuant to the provisions of the C ontractor's Licensed Law (Chapter 9 . Conunenci ng with Section 7000 of Div ision 3 of the Business and Profossions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any a pplicant for a penuit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). _l, as owner of th e propeny. or my employees with wages as their sole com pensat ion. wiJI do the work and the structure is not intended or offered for sale (Sec. 7044. Business and Professions Code: l11e Contractor·s License Law does not apply to an owner of the propeity who builds o r improves thereon. and who does such work himself or herself or through h is or her own e m ployees. provided that such improvements are not intended o r offered fo r sale. If. however. the building or improvement is so ld within o ne year of completion. the Owner Bu ilder will have the b1.1rdcn of proving that he or she did no! build or improve the propeity for the purpose of ,mle). _1, as owner of1he property, am exclusively contracting with lice,tsed contrnctors to construct the project (Sec. 7044. Bu.sin~ and Profession Code: T he Contractor's License Law does not apply to an own er of property who builds or impro,'es thereon. and who conlracts for such projects w ith a Contractor(s) licensed p ursuant 10 the Cont ractor's License Law). _I am exempt under Section ________ • 8. & P.C. for this reason. D~te: __________ Ow ncr:.~~-~~~--~-~------------- WORKERS' COMPENSATI ON DECLARATION l hereby affirm under penalty of perjury one of the following declarations: _.I have and will maintain a Certificate of Consent to Self-Insure for workers' compcnsntion. as pro vided for by Sectio n 3 700 of the Labor Code, for the pcrfonmmce of the work for which the pennit is issued. _l have and will mai ntain workers' compensation ins urance, as required by Section 3700 of the Labor Code. for the perfonnance of the work for which this permit is issued. My workers ' compensation insurance carrier and policy number are: Ca.Tier: __________________________ _ Policy Number: _____________________ E:<pires: __________ _ _I certify that in t he performance of the work for which this permit is issued. I shall not emplo y any perso n in any manner so as to become subject to the workers' compensation laws of California. and agree that if I should beco me subject to the workers' compensation provisions of Section 3700 of th e Labor Code, I shall. fo11hwith comply with those provisions .. WARNING: Fai lure to secure workers' compensation covernge is unlawful. and shall subject an employer to aiminal penalties and civil fines up to one hundred thousand dollars($\ 0.000). in addition to the cost of compensation. damages as provided for the Section 3076 of the Lobo r Code, in terest nd alto ·s fees._//"')_____, /I /"J /'J Date: ___________ A o ..-Y / / // / ~Yi l hereby affinn und er penalty of perjury that I run licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. L,ccnscClass ~ Date __________ -\➔/i ~~ I hereby affirm under penalty of pc,Ju,yt~is a construct,on len ding agency for the pe,fommnce of the work for winch th ,s permn is ,ssucd (Sec. 3097, Civ. C.) . Lender's Name: _________________________ _ Lender's Address: _________________________ _ APPLI CANT DECLARATIO N I hereby affinn under penalty of perjury one of the following dec larat ions: Demolition Permits-Asbestos Notification Federal Regulations (Tit le 401 Pan6) _Requ ired Letter of Notificatio n _I certify that the federal regulations regarding asbestos removal are not applicable to this project. -~t ify t I have read th ' lieation and state that the above infonuation is cmTecl. I agree to comply w i1h all City and County ordin 1ces, State U relating to uild" c~nstruction. and 1ereby authorize representatives of this City and County to enter upon the above 1 10ned p1 erty for inspc · s . Applic 11 or A em ure: /') 'A ./1 Date: Z,. /2 Y, /4 .-, ,, ,, V -I --=t'----=-~ Pe,nn am (print):_~'"-'.,...,Y--,.--1(.....-4(.,_,,_ _____________________ _ /