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MECHANICAL.I NSPECTOR RECORD APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hacby affim undq pcnalty of pcrjury thd I m qmp ftom thc Contructw' Licqrc law for thc following rwo (Sc.7031.5 Buines and Prcfsion Codc): Any City or Coutrty which rcquirG a pqmt to @nstruct. alta, imprcvc, rlcrnolish or rcpah my struc{uq prior to its isumcc. also rcquirc thc applicet for such pcBnit to filc E signcd stalmmt that hc or shc is limcd pmwt to thc prcvbioG of tlE Contrrctor'! Liccnrcd t:w (Chrptq 9, Comacing with Sclion 7000 of Divisbn 3 of rhc Bwine ud Prcfcsios Codc) or that hc or shc is cxrnrpt thqc&om ed the bssis for thc allcgcd amption. Any violation of Sdion 703 I .5 by ey applicatforapctrnitsubjetsthc applicuttoscivilpmltyofnotmrcthmfivchundrcddollus($500). -1. as owner of the propefiy, or my employecs with wages as their sole compensation, will do the work and thc structure is not inteirded or offered for sale (Se.7044. Business and hofessions Code: The Contractor's License Law does not ryply to an owner of the property who builds or improves thcreoq and who does such wort himself or herself or through his or her own employees. provided that such improvancnts are not intendod oroffired for sale. I( however. the building or improverneot is sold within one )€ar of cornplaioru the Orvner Builder will have the burden of proving thd he or she did not build or improve the propetty for the purpose of sale). -1. iN owner of the propcrtyr am exclusively contracting with licensed contraclors to construct the project (Sec. 7044. Btsiness and Profissbn Code: 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) licased purcuant to the Contractor's License Law). -larnexemptunderSection-.B.&P.C.forthisreason.Date:_ I hereby affinn Owner:--- WORKERS'CONTPE DECLARATION one of the follorving declarations:under penalty of pojury -l have and will maintain a Certificate of Conscnt to Self-Insure for workers' compensation, as provided for by Soction 3700 of the Labor Code for the performance of the wort for which the pcrrnit is issued. -l have and will maintain workers' compensation insurance, as required by Section 3700 of the labor Code, for the performance of the work for which this permit is issued My workers' compensation insurance caxrier and policy numh are: Policv Number: Exoires: -l certi& that in the performance of the work for rvhich this permit is issued. I shall not onploy any person in any manner so as to becorne subjcct to the workers'compensation laws of California. and agree that if I should become subject to the workers' compcrsation provisions of Section 3700 of the Labor Code. I shall. forthwith comply with thosc provisions.. WARNING: Failure to secure workers' compeuiation coverage is unlawful. and shall subject an onployer to criminal penalties and civil lines up to one hundred thousand dollars ($100.000). in addition to the cost of compcnsation. damages as provided for the Section 3076 of the Labor Code, interest and attorney's fees. Appllcant: I ICF'NSTD CONTRACTOR NECI {RATION I hereby affrm under penalty of perjury that I am licensed under provision of Chapter 9 (comrnencing rvith Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. License Class: License Number: W I hrcby amrm und6 penalty of psjury that th@ is a coNtruc{ioo lording agocy for thc pofollmcc of thc work for which this pamit is issued (Se. 3097. Civ. C.). Lender's Name: Lender's Address: APPLICANT NF'CI ^ RATION I hcr*y affirm under penalty of perjury one of the following declarations: Demolition Permits-Asbestos Notification Fedcral Regulations (Title 40. Part6) -Required Letter of Notification -l certi& that the federal regulations regarding asbestos removal are not applicable to this projed. -l cdiry thal I hryc Ed this application od statc thd thc abovc infomalion is cor61. I agre to smply with all City ard County ordinmcB ild Statc t m rclaing to building construciiorr and hreby authori* rcprcstativa of this City ud Couty to 6tq upotr thc aboE malioocd proFrty for iropafioo purpore. Applicant or Agent Permitee nalne (print ):_ Appliances Metal Fire Place Evaporative Cooler t I Furnace tur,?-k7 k),ffiT1 Compressor I f Misc. Equipment Duct Work Pre-lnsulation lnsulation Smoke Detectors lnstalled Rough Ductwork Vents Toilet Room / Clothes Dryer Residential Range Other Hood -Type I Hood Type !l Hood Grease Duct Fire Damper Openings lnstallation F.D. Drop Test Above Hard Lid Above T-Bar Rough Mech. Final Test Meter Release I I FINAL II llr,l',^0 1// Notes, Remarks, Etc.t I ('oltlritclor: