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M ECHANICAL.I NSPEGTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hftby affm und6 p@alty of pdjury that t u qcmpt ftom the Contncton' Liccns Law for thc following r@n (S6.7031.5 Busin6s od Profsion Codc): Any City or Coutrty which rcquirc a pomit to onstruct, alta. improvc dcmolish or rcpair ay structuc. prior to its issuucq also rcquis thc applicmt for such permit to filc I signed statcmot rhat hc or shc is licasad pwant to thc pmvisioc of thc Contrrctor's Lienrcd Law (Chaptfr 9, Comcncing with Sstioo 7000 of Division 3 of lhe Buins ud Prcfesions Codc) or thst hc or shc is crmpt thwfiom ud the bosis for thc allcgcd €xmption. Any violstion of S€ction 7031.5 by 6y applicant for a pcmit subjers thc applicut to a civil pcnalty of not morc th4 fivc hundrcd dollm ($500). _1. as owner of the property. or my employees with wages as their sole compcnsation. willdo thc rvork and the stnrcture b not intended or offercd for sale (Sec.7044. Business and Professions Code: The Contractor's Licerue l,aw does not apply to an owncr of the propoty who buil& or irprovc tlrenou and who does such work himself or herself or through his or her own employees. provided that such impovanrents are not intended oroff€rcd for sab. I[, howel'er. the building or improvemert is sold within one )€ar of complaion. thc Orvner Builder will have the hrden of proving that hc or she did not build or improve the property for the purposc of sale). -1, ES owner of the prop€rty, am exclusively contracting with licersed contractors to corstruct the project (Sec. 7M4, Business and Profcssion Codc: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contracto(s) licensed pursuant to the Contraclor's License Law). -l arn exenlpt under Section-. B. & P.C. for this reason. Drte: Owner: WORKERS' COTITPENSATION DECLARATION I hereby aflirm under penalty of perjury one of the follorving declarations: -l have and will maintain a Certificate of Consent to SelElnsure for workers' conlpensation, as providod for by Section 3700 of the Labor Code for the pcrformance of the work for which the permit b issued. -l have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the pcrformance of the work for which this pcnnit is issued. My workers'insurance carrier and policy number are: O Policy tD ' 54,-Ll -l certi& that in the pcrforrnance of thc work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California. and agree that if I should become subject to thc workers' compensation provisions of Section 3700 of the Labor Code. I shall. forthwith cornply with those provisions.. WARNING: Failure to sccure workers' compansation coverage civil fines up lo one hundred thousand dollars ($100.000), in Section 3076 of the labor Code interest and attorney's fees. is unlarvful. and shall subject an anployer to criminal penalties and addition to the cost of compensation. damages as provided for the o^r", ' ll'7V-? D I ICENSEI) CONTR.AC'I OR DECLARATION I hereby affrnn under penalty of perjury that I am licensed under provision of Chapter 9 (conrtnencing s'ith Section 7000) of Division 3 of the Business and Professions Code. an<l rny license is in full force and effect. I ll>/> 63 t+ bLicense o*",' I l- l, I- ? D contrecrorli-- I C(INS'I'RU("1'lON l.IrNDlNG A(;EN('\' there is a construclion lending agency fior the performance of the rvork for rvhich this po'mit is Lender's Address: ,rltc . Nt "ECt ^ I lro$y affrnn under penalty of perjury one of the follorving declarations: Dernolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) -Required Letter of Notification -l cstiry thst thc fcdEal rctulstioB rcgading BbBtos moval rc not eplicablc to thb prcj€{. Ucqity thil I luvc Ed this applicarion ad stdc thd thc abovc irformdion is coret. I agrc to omply with 8ll City and County lfdirucc md Statc kw Elding ro building constnrction {d hmby ruthorirc rcFecrtativc of this City ud County to 616 upon thc above mentioned propedy for Applicant or Agent Pennitee name (r Appliances Meta! Fire Place Evaporative Cooler Furnace t2l7l74 bktr 8 7 Compressor t1,h l>rl h,,,r/J.#'7 ItIisc. Equipment t -l I Duct Work Pre-lnsulation lnsulation Smoke Detectors Installed Rough Ductwork Vents Toilet Room / Clothes Dryer Residential Range Other Hood Type I Hood Type ll Hood Grease Duct Fire Damper Openings Installation F.D. Drop Test Above Hard Lid Above T-Bar Rough Mech. Final Test Meter Release It I F!NAL lU7l7////0/,1-w ry Notes, Remarks, Etc.lt o 0