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M ECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby allirm undcr pemlty of Friury that I m cxcmpt from the ContncloF Lkrns Lrw for the following rcs$n (S1c.7031.5 <br />Business ard Prcfcssion Codc): Any City or County whbh rcquircs a prmit to onstruct. altcn imprcve. demlish or rcp8ir rny <br />structre. Fior lo its issure. als rcquires thc applicant for such pcrmit to file I signed staleGnl that he or shc is lien$d ptmrnt <br />to thc prcvishns of the ContEctor's Lien*d kw (Chaptcr 9. Commrcing wilh Sation 7fi)0 of Division 3 of thc Busircss rnd <br />PrcfcssionsCode)orthathcorshcisexcmptthwfrcmandthe brsisforthcallcgcdexemption. AnyvklstionofsclionT03l.5byany <br />applicanl for 8 ]Emit subjets the spPlicant to 8 civil pemhy of not mrc lhu fivc hu.drcd dollars ($50O). <br />_1. as owner of thc property. or my employc.es with wages as thcir sole compensslion. will do the work Bnd the structure is not <br />intcnded or offered for sale (Scc.7044. Busincss and Profcssions Code: The Contractor's License l-aw docs not apply to an owner of <br />thc pmJrcrty wlrl builds or inprorrcs thcreon. and wtn docs such work himself or herself or through his or her own employces. <br />provided that such improverncnls arc not intcndcd or offcrcd for sah. If. however. thc building or improvenrnt is sold within one )rcar <br />of complction the Orrner Builder will have the burden of proving thal hc or shc did rnt bnrild or improrrc the propcrly for the purposc of <br />salc). <br />_1. as owner of the propcrty. am exclusivcly contracting with liccnscd conlractors lo construct thc pro.icct (Sec. 7W. Business <br />and Prrofcsskrn Code: Thc Contractor's Liccnsc Law docs not apply lo an owner of pro;rcrty who huilds or improvcs thercon. <br />and who contracts for such projects with a Contracto(s) licenscd pursuant to the Contractor's Licensc taw). <br />-l <br />am cxempt undcr B. & P.C. for this reason. <br />( )rr nrr <br />WORKERS' COMPENSATION <br />DFCI ARATION <br />I hcreby affirm undcr penalty of pcrjury onc of the following declarations: <br />_lhavcantlwill rruintainaCcrtilrcitte<ll'ConsclrtloScll'-lrrsurcfrrrworkcrs'cornpcttsution.as providcdforhyScclionSTfi)ofthc <br />Lahrr C}xlc. for thc pcrfornnncc of lhc u'rlrk for which thc pcrrnit is issucd. <br />-l <br />havc and will rnaintain workers'Section 3700 of the [-abor Codc. for thc performance of <br />thc work for issucd.carricr an<l number arc: <br />a 11, <br />IPolicy <br />_l certify that in thc perforrnancc of the work for which this pcrrrrit is issued. I shall not ernploy any pcrson in any manncr <br />so ns to bcconrc subjcct to the workcrs'contJrcnsalion laws of California. and agrcc lhal if I should bccomc subict to lhe <br />workcrs' cornpensation provisions of Scction 37fi) of thc Lahor Code. I shall. l'orthwith cornply with thosc provisions.. <br />WARNING: Failurc to liccurc workers'compensation covcrage <br />dollars ($1ffi.000). in <br />and attorncy's fc.es. <br />is unlawful. and shall subject an employer lo crirninal Jrcnalties and <br />civil fincs up t<r hurrdrcd addition lo thc cost of damages as provided for thc <br />Section -i076 inlcrcst <br />o 0 <br />l)l'lCL,\Rr\'l'l()N <br />I hercby aftirm under pnalty of perjury that I anr liccnscd under provision of Chaptcr 9 (contmcncing with Section 7Un) of Division 3 <br />of the Business and Profcssions Codc. and rny liccnsc is in full frrrcc and cll'cct. <br />Liccnsc - <br />t Contracto.'( <br />W <br />I hcrcby !flirfl undcr ]Enulty of pcrjury that therc is a construction lcnding agcmy for lhc performncc ofthc work for which lhis lsmil is <br />issucd (Sc. 3097. Civ. C.). <br />kndcr's Namc: <br />lrndcr's Addrcss: <br />. prl ,c . NT I'EC, . <br />I lrcrcby allirm under penalty of pcrjury onc of the following dcclarations: <br />Denrolition Pcrmits-Asbestos Notification Fcdcral Regulations (Title 40. Purt6) <br />-Rcquircd <br />lrttcr of Notificalion <br />with lll arxlCourrly <br />and <br />atrovc nrcntioncd propcrly for inspcction <br />Applicant or Agent <br />Pernritcc narrrc (print <br />\,q to <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler tl <br />Furnace u lalh a kkN <br />Compressor I I t <br />Misc. Equipment <br />Duct Work <br />Pre- lnsu !ation <br />!nsulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type !l Hood <br />Grease Duct <br />Fire Damper <br />Openinqs <br />Installation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech <br />Final Test <br />Meter Release , <br />FINAL lt l/ula ;9 <br />Notes, Remarks, Etc.I <br />+ <br />Date:_ <br />illsttrancc. as <br />:*conrpcnsaliorr <br />I/1 <br />Exnircs:? <br />ffi <br />a <br />\ <br />-Liccnsc <br />Numbcr o <br />€)€JLr'frratL ft, <br />l)ftv,