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MECHANICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNEN BT'ILDER DELCARATION <br />I hcrcby afnrm urdq lEmliy of pcrjury thst I m crcmpl ftom lhe ContrrctoB' Licens lrw for rhc following mmn (Sc.7031.5 <br />Business 8nd Prcfession Codc): Any City or County which requircs a pcmit to mnstruct, alls. imprcw. dcmlish or rcpair any <br />structurc, prior lo its issumce. slso rcquircs thc spplicsd for such pemil lo frlc a signcd statemnt that he or shc h liccnrd pumant <br />to the provisions of the Contrctor's Licnsd hw (Ch8ptcr 9. Colrrerciog with Section 7000 of Division 3 of tlE Busine$ snd <br />PrcfessionsCode)orthallEorsheiscxemptthscfromardrhebosisforthcsllegederemption. AnyviolationofSctkln703l.5bysny <br />applicrnl for a lrmit subjcrls thc applicant to a civil pemlty of rct mrc thm Iive hundrc{ dollus ($500). <br />-1. <br />as owncr of thc property. or my employees wilh wagcs as their sole compensation. will do the work and the structurc is not <br />intendcd or offercd for sale (Scc.7044. Busincss and hofcssions Codc: The Contractor's License l-aw does not apply lo an owncr of <br />thc propcrry who builds or improves thcrcon. and who docs such work hirnself or herself or lhrough his or hcr own employees. <br />provided lhat such improvenrnts are not intended or offcred for sale. lf. howerrcr. lhe building or inqrroverrnt is sold within one )r&r <br />of complction. thc Owncr Builder will have the burdcn of proving that hc or shc did not build or inprorre tlrc propcrty for the purpsc of <br />sah). <br />-1. <br />as owncr of the propcrty. am exclusively contracting with licensed contractors to construct thc project (Sec. 7044. Business <br />and Prrofcssion Code: Thc Contractor's Liccnse Law does not apply lo an owner of property who builds or improvcs thcrcon. <br />and who contracls for such projects with a Contractor(s) licensed pursuanl to the Conlractor's Liccnse t aw). <br />-IamexemptunderSection-.B.&P.C.forthisreason.Date:( )u ner <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hcrcby atTirnr undcr penalty of perjury one of thc following declarations: <br />-l <br />havc and will maintain a Certifrcate of Consent to Self-lnsure for workcrs' comSrensalion, as provided for by Section 3700 of the <br />I-abor Code. for the grrformance of the work for which thc permit is issucd. <br />Qf"tmr*rvill 37fi) of the Labor Code. for thc Jrcrfbrmancc of <br />grlicy numbcr are: <br />a h <br />O <br />Policy o <br />-l <br />ccrtify that in the performance of the work for which this pcrmit is issucd. I shall nol cmploy any person in any manner <br />so as lo bccomc subjcct to thc workcrs'compcnsation laws of California. and agrcc that if I should hccome subjcct to thc <br />workcrs' compcnsation provisions of Section 37fi) of thc l.irtnr Codc. I shall.comply with those provisions.. <br />WARNING: Failure to sccurc workcrs' comlrcnsation covcragie subjcct an employcr to criminal penaltics and <br />civil fincs up thousand dollars (Slfi).000), in of compensation. damages as providcd for the <br />Scction 3076 of Code. intcrcsl and atlonry's fces. <br />I hereby affrm under penalty of perjury that I am liccn:rcd under provision of Chapter 9 (comnrcncing with Section 70m) of Division ! <br />of thc Busincss and Profcssions Codc. and my liccnsc is in full force and cffcct. <br />t <br />Licensc <br />a <br />a <br />I hcrcby alllrm under penalty of pcrjury that thcrc ilgcncy pcrfonnancc of thc work for which this Jrcrmil is <br />issued (Scc. 3097. Civ. C.). <br />Lcndcr's Namc: <br />Lrndcr's Addrcss: <br />pp, tcANT DECL RA'IN <br />I hcrcby aflinn undcr penalty of pcrjury one of thc following declarations: <br />Dcrnolition Permits-Asbcstos Notification Fedcral Rcgulations (Title 40. Part6) <br />-Rcquircd <br />[-cttcr of Notification <br />rcgarding asbcstos urc nol applicablc to this projcct. <br />is correct. I agrcrc to cornply with all City and County <br />rcprcscntativcs of this City and County lo cnter u;ron lhc <br />atlove menlioncd propcrty for <br />lhal <br />f\nra. J <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />Insulation <br />Smoke Detectors lnstalled <br />Rough Ductwork <br />Vents Ir I <br />Toilet Room I Clothes Dryer dtlt%^rW>7Residential Ranoe (Il- <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 />Final Test <br />Meter Release t\h <br />FINAL bv\10 D {f\rd 4\p"\ <br />Notes, Remarks, Etc.\\ <br />-.> <br />Drtl^,r1)tnsurancc. as <br />pcrrnit is u'orkcrs'conrpcnsation <br />Exoircs: <br />w contracror:Date:- <br />rcad this <br />Applicant or Agent Signature, X <br />Pcrmitcc namc ( printl:r\(,l-"llur