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DATE ID/SIG.COMMENTS OWNEII BUILDER DELCARATION <br />I hsdby alIm lndd ncMlry of D.rjury lhd I m.x.no fmm lh. C.ntEclon Lien* kw for E folloshB t@$. (Sd.7031.5 <br />Blsi6s .nd ftofcsion Cdc): Any Cily or Cohly which Equirci ! tdnil b snslru.t. altf. intphE. &mlish or EPan 8nt <br />srructurc. !!ior lo irs nsusie. !l$ equnes rhc q,plkd lor such lcmi ro tilc r signcd 3tdeBd lnal It or snc is liccnscd pusua.r <br />o rlE pDvl\ions ol tlE Conrrerols Liansd Lls (Ch!pr.r 9. Comftins witt S*rk n 7000 of Divirion 3 of llE Blsitue rnd <br />Pofcssiotrs Codc) or thar lr or slr is crcnw thceftonsd rhc h$is for rhc alhg.d.xompion. Anyvioldknoasc.lion7011.5 bya.y <br />aprliclnr for a ncmir rubjdk tts lmlictr.l roacivilp.mllyolnol noElhsn firc hlndEd dollos ($500). <br />L as o*mr of rhc rmpcny. or my cnploles sirh saScs as rh€ir $kj (om!.nerion. siI d. thc *Gk !d tlE sllllcie i mr <br />ir cndd or ofrc(n for sk (56.7044. Blsine* 6.d Prolcssioni Coicr Th. Conkoctols Lian$ Lsw dcs nol sDdy ro an owrcr ol <br />rhc pn,pcny who btrilds or iipmws lh.6( .d who dms sch wlt timscll or icrslr or rhrough hh or hfi own crylloltcs. <br />prcvidcd rlur such ir{mwmnk d mr inlcid.n or ofi.rd lor elc. It howcwi llE toildins br in9hwsfl ir$td wnhinom r- <br />oisnphrion. tlE OwN Buitti eill lEw r,E bod.i ollmline lhar lE or $. dal rcl hiki or upow tlE P,DFIy for lt puills ol <br />-1. <br />s o*Br ofrlE p,oFny. d cxclusiEl, oflr&ring wnh lklnsd co,tracrm ro .onsuu.r th. pmj.tl (56. ?0!4. ButiKi <br />ain Enf*sir Code: Th. C6nr&r6l s liccBr Lrw docs .or apply to & owncr of prcFny eho blilds or inpmvcs Ihdcon. <br />and who co.tads fu sucn pmirts wilh a CotrtMro(s) li.cMd tu u b rhc Conlraclols Lien* tiw), <br />I .o .r.opl un Lr Sdlion- B. & P.c. for lhir rc&en <br />I{Of,TEf,TI:OMTENSAIION <br />DECI,AB6:ITQN <br />I hcrcby at'lirm undf ,,cNh, ol !.rjury .nc of lhc lollowi.g d(ldaions: <br />-l <br />novc {d *ill rointlin u Ccnificarc of Con$nr r. s.lr.ln\Dft ror wo cs ompctr$ti.tr. !s rrelidcd lor bysdriotr r70oolrhc <br />tjtxtr Cod.. for lhc pcrrbrmn.c olthc *o* fo,qhichrhc pc,mil is nskd. <br />-l h.!e ond will 'nlinrain <br />wo*.u omp.nsrrion insu6ec. .r rcqut d by sdion 3?00 of lh. Lsl'or Cod.. lor thc lEfol1rec of <br />thc *ork for which rhis lemir is is$e.L My *orkdl @npcnr.rion ansull@ .ujcr &d Flicy numbcr m: <br />U/, <br />-l <br />ccnify rnat itr rhc llcrforrone ofr,r work ror whkh rhh p.hir is issucd. I shdlnol ctr{,loy !"y pc^oo io &., mhn$ <br />$ as ro tEotu slhJccr ro rh. wo*ds oq,.ns.rion laws ol C,lifomia. and usB rhar if I ilt,uld b..om subr.tr to lhc <br />workcs od,rnsarbn provhions of Scclion 3700 oflhc btrr Code I shall. fonhwilhcoorly wnhrhoE provhions. <br />WARNINC: FailuE ro scurc woik n mqxnsriof, cov.ngc Ls !nl.*tu|. ond shall sutrcr d cnll}hrt. lo aimiml lEnollis 8nd <br />cilil lincs !p lo otu huidEd rhousrnd dollars ($100.0(U). in addilion lo thc cost of co nncnsar io n. .lsm8.s !s prolid.n {or lhc <br />Scrion 1076 ol rhe Lltnr Gdq intc[i rnd anomyt ic.s <br />IICINSEILCONI&II:IAf, <br />DICIABIIUAN <br />I hcrchy trliirnr u ndcr pcnrlry of p$jrry rhar I n lircn*d uMf Brvir irnr of ChrPrcr 9 (co'n *'tnr8 qnh SNrb. Tu)Or ol Diri\ion .l <br />ol rhc Bu{n$\ud Pml!$n,nrCodc. afll n,y liLc \. N i0 tullnt.. ! clii.r <br />t)/1/frt <br />COISIBUEIIONIIIDIIGJCIiM:} <br />i\sucd lsc. :l(rO7. Civ C ) <br />AfILICANLIESA&UIAN <br />I holhy tr 'm hdcr prn3lry ol l.rjury onc ol rh. h,hwinS dNlalt ion\: <br />Dc.rlirn'n Pennirs^sEnos Nolilicari,)n Fddcrdl Rcgolzri,'ns (Tntu 40. Pd6) <br />-Rcquncd <br />Letrcr ol Norirr.rbn <br />-t <br />anilrrh rhe fcdcdlrcghlions rcSedin8 lsbcslos Emvll!e nol aprli.lhlc ro lhis pmlrl <br />I ccnify rhll I have rcsd rhis aNlicd ion Md $!tc thal (hc atsv. inaormlio. is .omcl. I lEE lo onPly wilh aI Cny ud C.unty <br />ordinanccs ood Srarc Lrwi rclating io buildi.S con(ruclior ond hcrcby lulhorir. reprcsntdivcsoflhis Cily ud Counry lo cnrq ulon tlE <br />uhne mnr i{,n.n pn,I'.ny for <br />Apdiconl or AScnl Sisnar! <br />**r-ru <br />'/-a <br />Appliances <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork <br />Vents <br />Toilet Room i Clothes Dryer <br />Residential Ranoe <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />lnstallation <br />F.D. Drop Tesl <br />Above Hard Lid <br />r\ <br />Rough Mech.(w"\{cJ) <br />Final Test IX <br />Meter Release a\ <br />FINAL 2*}rilrt)u <br />Notes, Bemarks, Etc.\l <br />MECHANICAL-INSPECTOR RECORD <br />1 <br />APPROVALS <br />Itrletal Fire Place <br />Above T-Bar <br />l- /- )ut4 <br />".^,*,*,FtjUzA t- <br />^, {-}s- F <br />- <br />: <br />:f-------r------ <br />I