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MECHANICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNERBUILDENDELCARATION 'I hcrctry affum under pcnrlty of perjury thd I m cxcmpt frcn thc ContrrctoB' Liccns liw for the following rcamn (Stc.7031.5 <br />Business ard Prof6sion Code): Any City or County vhich rcquircs a lEmil to anstruct. slts. improrc. dcmlish or rcpsh rny <br />struclurc, prin to ils issumc, als rcquiffi the spplicant for such pcmit k file a signcd statcmnt thal he or she is licensd pur$arl <br />to thc prcvisions of the Contractor's Licensd bw (Chapter 9, Commcrcing with Scction ?(x)0 of Division 3 of the Business rnd <br />PrcfessionsCode)orthatheorshcisexemptthrcfromandthcb&sisfortheallcgcdexcmption. AnyviolationofscclbnT03l.5bysny <br />applicant for a pcrmit subi{ls lhe applicant to a civil peulty of ret mrc thrn five hudE{ dollus ($500). <br />-1. <br />as owncr of the propcrty, or my cmployees with wages as thcir sole compcnsation. will do the work and the structure is not <br />intendcd or offcred for sale (Scr.7044. Busincss and Professions Code: The Contractor's Liccnse l-aw does not apply to an owner of <br />the proprry who builds or improvcs thersrn. and whcl does srrch work himself or hersclf or through his or her own employees. <br />provided that such improvenrnts are not intendcd or offered for sah. lf. tro*'cver. the building or improvenrcnt is sold within one )car <br />of complction. thc Owner Buildcr will have thc burdcn of proving lhat he or shc did not build or improve the property for the purposc of <br />sah). <br />-1. <br />as owncr of the propcrty. am exclusivcly conlracting with liccnscd contractors to conslruct thc projcct (Sec. 7M4. Busincss <br />and Profcssion Codc: Thc Contractor's Liccnse Law does not apply to an owner of propcrty who builds or improvcs thcrcon. <br />and who conlracts for such projccts with a lo thc Conlraclor's Liccnsc Law).\ <br />-l <br />am <br />I hcrchy affirrn undcr penalty of pcrjury onc of thc firlkrwing <br />-l <br />have and will maintain a Certificate of Conscnt to Self-lnsurc for workers' compensation, as provided for by Scction 3700 of the <br />l-abor Codc. for the performance of the work for which the permit Ls issucd. <br />-l <br />have and will maintain workers' compensation insurance. ns rcquired by Scction 3700 of the Labor Codc. for thc performance of <br />the work for which this permit is issued. My workcrs' compensation insurance carrier and plicy numhcr are: <br />Policy <br />a <br />_l ccrtify that in the Jrcrformancc o[ the work for which this pcrnrit is issued. I shall not cmploy any pcrson in any manner <br />so as to becomc subject to thc workcrs' compensation laws of California. and agrce that if I should bccomc subject to lhe <br />workers' cornpcnsalion provisions of Section 3700 of the L-abor Codc. I shall. forthwith comply with those provisions.. t <br />WARNING: I:uilurc to sccurc workcrs'lnrl slt:rll suhject an crnploycr to criminal pcnaltics and <br />compcnsution. danragcs as providcd for thccivil fines up to lhousarttl dollars thc cost of <br />Scclion intcrcst and I <br />I hercby affirm under pcnalty of perjury that I am licensed undcr provision of Chapter 9 (commerrcing with Section 7000) of Division 3 <br />of the Business and Professions Code. and my liccnse is in full force and ctfcct. <br />License Class: License Number: <br />I ):rlr' ('olrl r:rt'lor <br />CONS'IRUCTION LENNTNG A(;ENCY <br />I hcrchy aflirnr undcr pcnally of pcrjury lhill lhcrc is o ()nslructi(il lcnding ilgcncy tbr thc Frfornuutc of lhc work tirr which this ;rcrrnit is <br />issucrl (Scc. 1097. Civ. C.). <br />l,cndcr's Namc: <br />l-cndcr's Addrcss: <br />APPI ICANT NT'CLARATION <br />I lrn:by alfirrn unclcr pcnalty of prjury onc of thc following dcclarations: <br />Dcrnolition Pcrrnits-Asbcstos Notification Fcdcral Rcgulations ('l'itle 40. Part6) <br />-Rcquircd <br />lrltcr of Notilication <br />-l <br />certify that lhe fedcralrcgulations rcgarding asbcstos rcnmvalarc not npplicablc to lhis projcct. <br />\ t <br />""rtirythat <br />I haveread this lhat thc atxrvc information is correct. I agrcre to comply with Courrly <br />ordinanccs and State laws <br />abovc mcntioncd property for <br />Applicant or Agcnl <br />Pcrrnitcc namc (print): <br />ailhorize reoresentalives.\of this City to u;xrn thc <br />Appliances <br />t\Ietal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />[t/isc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors Installed <br />Rouqh 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 Damper <br />Openings <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech <br />Final Test <br />Meter Release t -tr-t <br />FINAL I U lvYL)/wb <br />Notes, Remarks, Etc. <br />a <br />D - <br />Carrier: <br />Exnircs: <br />IS <br />Dalc: