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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hereby allirm undcr pcmlly of pcrjury that I m exempt from thc ConlIqcto6' Licenrc lnw for the following rcasn (Sec.7031.5 <br />Business ard Prcfession Code); Any Cily or Counly which rcquircs a fEmit to enstruct. alto, improrc, demlish or rctEir rny <br />slruclurc. prior to ils issurnce, also rcquires thc +plicant for such Fmil to filc s sigrcd statcmnt lhal hc or shc is liensd pususnt <br />to the prcvisions of thc Contrcttr's Liccnsd t w (Chaprcr 9. Comrurcing with Sslion 7000 of Division 3 of thc Dusircss rnd <br />PmfcssionsCodc)orlhatheorshciscrcmptthcrcfromandthebasisforthcsllcScdexemption. AnyviolationofscaiooT03l.5bysny <br />applicant for 8 pemit subjGts thc rpplicant to s civil pemlty of not mrc than five hundrcd dollus ($50O). <br />-1, <br />as owner of thc propcrty. or my employees with wages as thcir xlle compens&tion. will do the work and the stnrrurc Ls not <br />intcnded or offercd for salc (Scr.7044. Business and Professions Code: Thc Contractor's Liccnse l-aw does not apply lo an owner o[ <br />the prof,crly who builds or impmves therf,$n. and who does such work himself or hcrrclf or lhrough his or her own employees. <br />providcd that such improvcnrnls are not intended or offered for salc. If. however. thc building or inprovenrcnt is sold within one )rcar <br />of complction. the Owner Buildct will have the burdcn of proving that hc or shc did not build or improve the property for thc purynsc of <br />sale). <br />-1. <br />as owncr ol'lhc propcrty. artt cxclusivcly conlracting with liccnsctl conlraclors lo conslruct lhc projcct (Scc. 7fi4. Busincss <br />itnd ProlcssionCoclc: '[hcC<lnlrilctor'sl.iccnscl.awdocsnotapplytoanowncrofpropcrlywhohuildsorimprovcsthereon. <br />antl who conlracls lor such projccts with a Contraclor(s) liccnscd pursuarrl to thc Conlraclor's l-icensc Law). <br />-l <br />arn cxcnrpt undcr Scction-. B. & P.C. lbr this rcuson. <br />( )rr lrrr: <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hcrcby affirnt undcr penalty of perjury one of lhc following declarations: <br />-l <br />have and will maintain a Certificate of Consenl to Self-lnsure for workers' compcnsation. as provided for by Section 3700 of the <br />Labor Code. for thc performance of thc work for which the pcrmit is issued. <br />-l <br />havc and will by Section 3700 of the Labor Code, for the lrrformance of <br />and policy number are:thc work for issuc'd.canicr <br />a a <br />C <br />pl nlu['olicy o <br />-l <br />ccrtify that in thc performancc of thc work for which this permit is issucd. I shall not employ any person in any manner <br />so as lo bccome subjcct to the workers' comJrcnsation laws of California, and agrcc thal if I should become subjcct lo thc <br />workers' comJrcnsation provisions of Section 3700 of thc l;rbor Codc. I shall. forthwith comply with thosc pmvisions..t <br />WARNING: Failurc lo sccurc workcrs' compcnsation covcr.rgc is unlawful. and shall subjcct an employer to criminal pcnalties and <br />civil tincs to onc hundrcd thousand dollars (Slm.fin), in addition lo thc cost of as providcd for the <br />Scction intercst and altorney's fccs. <br />LICENSED C(IN'IIIACTOR <br />DECLARA'TION <br />I hcrcby allirrn undcr penalty of pcrjury lhat I arn liccrrsccl undcr provision ol'Chuptcr 9 (comnrcncing with Scction 7Un) of Division -1 <br />of thc lJusiness and Prol'cssiorts Codc. ard nty licensc is in full frrrcc iurd clTcct. <br />c20 U6HS3l.iccrtsc <br />l)nle:'?_a <br />W <br />I hercby affrm undcr pcmlly of Friury that therc is s oNlruction lcndirg 8gercy for the Frfom of thc wr* for which this pcmil b <br />issued (SG. 3097, Civ. C.). <br />Lcndcr's Namc: <br />[,cndcr's Addrcss: <br />A PPLICAN'T DT'CLARATION <br />I lrcrchy aflinrt undcr pcnalty of pcrjury onc of thc followirrg dcclarations: <br />Dcnrolition Pcrnrits-Asbcstos Notil'icalion l.cderal Rcgulations (l'itlc 40. Part6) <br />-Rcc;u <br />ircd l-cl lcr of Notilical iorr <br />-l <br />ccrtify that the fedcralregulations asbcstos renrovalnre nol applicable to this projcct. <br />-l <br />ccrtify that I havc rcad this statc that the atnve inlbrmation is corrcct. I agrcrc to cornply with all City and County <br />ordinances and Statc [-aws rclating to of this City and County to entcr upn thc <br />above mcnlioncd propcrty for insJrcction <br />^,,r^,qlt't,,Applicant or Agent <br />Pernritce namc (print <br />conslruclion. and aulh()rizc <br />Appliances <br />N/etal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />lt/isc. Equipment <br />Duct Work <br />Pre-lnsulation <br />Insulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork <br />Vents <br />Toilet Room I Clothes Dryer <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type !l 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 />Fina! Test <br />Meter Release <br />FINAL ll'l')'-tV tywl/d 7&+( <br />Notes, Remarks, Etc. <br />Exoires: <br />t Conlrnclor: