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M ECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hercby affirm undcr pcnslty of Frjury that I m cxctrtpt from the Contrrctos' Liens Lrw for the following rctwn (Scc.7031.5 <br />Busiress and hofession Codc): Any City or County which rcquires a [Emh to @nstrucl, slts. itr{,rcre. &mlish or rcpah any <br />structurc. prior lo its issuare. dm rcquircs thc rpplicant for such pcmit to lilc I signcd stslemnt thal he or drc is liensd pusant <br />to thc prcvisions of the Contrrctor's Liccnsd llw (Chaptcr 9. Comcncing wilh Sstion 7000 of Division 3 of the Busircss and <br />Pmfcssions Codc) or thst hc or she ir cxempt th€rcfrom ard thc basis for the alhgcd crcmption. Any violation of Setbn 703 L5 by any <br />applicant for a pmit subjcls thc spplicrnt to 8 civil pcnalty of not mre lhsn ,ive hundrcd dollus ($50O). <br />_1. as owncr of the propcrty. or my employees with wages as their sole compensation. will do thc work and the stnrcture is not <br />intcndcd or offcrcd for salc (Scr.7o4a. Busincss and hofessions Code: Thc Contractor's License [:w docs not apply to an owncr of <br />thc propcrty who builds or in{rroves thcreon. and who does such work himself or hersclf or through his or her own cmployees. <br />providcd that such improrrcnrcnts are not intcrdod orofferpd for sah. lf. howcvcr. the building or irrrynoverrnt is sold within onc )ear <br />of complction. the Owner Builder will have thc burden of proving that he or shc did not build or improvc the propcrty for the pur;nsc of <br />sah). <br />_1. as owncr of'the propcrty. anr cxclusivcly contracting u'ith liccnsed conlruclors lo conslruct thc' projccl (Sec. 71A4. Busiltcss <br />arrtl PnrfcssklnCoclc: 'l'hcConlractor'sl,iccnsc[.awdocsnotapplyloanowncrofpropcrtywhohuildsorintprovcslhcrctttt. <br />and who contracts ftrr such projccts with a Clontraclor(s) liccnscd pursuanl to lhc Conlraclor's Liccnsc Law). <br />-l <br />arn exenrpl undcr Sccliort-. B. & P.C. tbr this rcason. <br />I)nle: <br />WORKERS' COMPENSATION <br />DECLARATTON <br />I hcrcby affirnr undcr pnalty of pcrjury onc of thc following dcclarations: <br />_lhavcamlwill rnainlainaCcrlilicatco[ConsclrlloSclf-lnsurclirrs'orkcrs'cont;rcnsalion.as provitlcdforhyScction-]7(X)o[thc <br />[;rtxrr Codc. f<rr thc pcrlbrnuncc of thc s,ork frrr u'hich thc Jrcrnrit is issucd. <br />_l havcandwill rnaintairrworkers'corrrpcnsatiorrirrsurancc.as rcquircdhy.Scction3T(DofthcLtllorCodc. lirrthcpcrforttnttceo[ <br />thc work for pcrmit is issucd. My workcrs' conrfrcnsatiun insurancc carricr and gllicy numbcr arc: <br />D <br />t O tPolicy <br />Vlccrtify thar in the performance of the work for which this yrcrmit is issucd. I shall nor cmploy any lrcrson in any manncr <br />should hccomc subjcct to thcso as to bcconrc subjcct <br />workcrs' compcnsation <br />to thc workers' cornpensation laws of California. anrl agrcc that if I <br />provisions of Section 3700 of the Latnr Code. I shall. forthwith comply with thosc provisions.. a <br />WARNING: Failurc to sccurc workcrs'cornpcnsalion coveragc is shall artrl <br />tltccivil fines up to onc dollars ($100.000). in <br />and attorncy's fees. <br />cost of <br />Scclion 3076 of the intcrcst a <br />i o <br />LICENSED CONI'RA C'I'OR <br />DECLARA'I'ION <br />ol' tlrc Busincss anrl Prol'cssions Cotlc. :rtrl tny liccrtsc is in lirll tirrcc antl cl'ttct. <br />a C7 a +1 81Liccnsc <br />o x <br />W <br />I hcEby sffum urder penslty of perjury thst therc is 8 snstructk n hndirg 8gcrcy for thc pcrfoffic of the mrk for which thir tHmit is <br />issucd (36..30117. Civ. C.). <br />Lcnrlcr's Nanrc: <br />Lcndcr's Addrcss: . *"LIC -Nt t."cLA <br />I hcrcby affinn undcr pcnalty of prjury onc of thc f<rlkrwing declarations: <br />Dcrnolition Pcrrnits-Asbcstos Notification Ftderal Rcgulations ('Iitlc 40. Part6) <br />-Rcquircd <br />lrttcr of Nolificalion <br />-l <br />certify that the t'edcral rcgulations rcgading asbcstos rcnxrvalare applicublc lo lhis projcct. <br />$Arccrrify that I havc rcad rhis applicarion urd <br />abovc rncrrtionctl propcrly lirr ilts;lcctiort <br />Applicant or Agcnl <br />Pcrrnilce nurrrc <br />thc I agrce to comply with all City and County <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 Range <br />Other <br />Hood <br />Type I Hood <br />Type Il Hood <br />Grease Duct <br />Fire Darxper <br />Openinqs <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Fina! Test <br />Meter Release I ^l -tt \,l ^ t./ <br />FINAL tli-w 4 '(ro urr.w6"l <br />-Tt t,I <br />{ <br />Appliurnt: <br />Oate: r f <br />ordinanccs and Stalc Laws rclating to WI <br />of this City <br />- Datc: ' <br />Notes, Remarks, Etc.