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M ECHANICAL-I NSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION t hmby sffm und6 pcralty of pqjury thd I m cxmp ftom thc ContEctoB' Liccre kw for thc following rmn 156.7031.5 Buines md Profeion Codc): Any City or County which rcquic a pcmit to oNtruct. alt6. imprcvq dcrfolbh or Epair my structurq prior to its isumcc. also rcquiro thc qplicsnt for such pcrmit to lilc a siSncd stal@dl that hc or shc is lictrcd plmet to thc provisioN of the Clntretor's Licmscd law (Ch.pt6 9. Commmcing with SElion 7000 of Division 3 of thc Busins md Prefxions Codc) or that hc or shc is cxcmpt th@from od thc bais for thc allcgcd cxmption. Any violation of S*rbn 7031i5 by any applicant for a pcmit subjcts thc applicart to . civil pcnalty of rcl morc thm livc hundred dollus ($500). _1. as owner of the property. or my employees with wages as their sole cornporsation. will do the work and the structure is not intcnded or offered for sale (Sec.7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of the property who builds or improves thcreon. and who does such rvork himself or herself or through his or her own employec. provided that such impovonents arc not intcnded or offcrod for sale. If. hower,rcr. the building or irnprovement is sold wilhin one )aar of complaion the Orvner Builder u'ill have the burden of proving thr[ he or she did not build or inprove the propaty for thc purposc of sale). -1. as owner of the property. am exclusively contracting with licensed contractors to construct the poject (Sec. 7M4, Business and Profiession Code: The Contractor's License Law does not apply to an orvner of property rvho builds or improves thereon, and who contracts for such projects rvith a Contracto(s) licensed purcuant to the Contractor's License Law). -l am exempt under B. & P.C. for this reason. f)o t o. WORKERS' COIITPEN SA'I'ION DECLARATION I hereby affirm uncler penalty of perjury one of the follorving de<larations: __ _l have and rvill rnaintain a Certificate of ('onsent to SelGlnsure for u'orkers' compensation. as provided for by Section 3700 of the l.alxrr Code. for the perfonnance of the u'ork for s'hich the pornit is issued. - I have and will rnaintain rvorters' cornpensation insurancc. as required by Section 3700 of the Labor Code, for the perforrnance of the u,ork for rvhich this pcnnit is issued. My worko's' cornpensation insurance carrier and policy nutnbcr are: Policy N,.mhar.Irrpircs: _ _l certifu that in the perforrnance of the work for rvhich this perrnit is issued. I shall not employ any person in any manner so ils to become subject to the rvorkers' compensation law's of California. and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall. forthrvith comply rvith thosc provisions.. WARNING: Failure to sccure rvorkers' compensation coverage is unlawfiul. and shall subject an anployer to ctiminal panalties.and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of comperuiation. damages as provided for'the Section 3076 of the Labor Code, interest and attorney's fees. t LI('ENSED CONTRAC'TOR DECLARATTON I hcreby affinn under penalty of perjury lhat I am licenserJ under provision of ('hapter 9 (comtnencing u'ith Section 7000) of l)ivision -1 of the Business and l\ofessions Code. and my license is in full force ancl effc'ct. l.icense Class:_ l)nl c:/ CONSTRUCTION LENI'ING ACENCY I hatby affm undr pcElry of pajury thd th@ b E srdruction kodiry rgacy fo. thc Ffotrlmc of thc wrl for wlich thb pqnit b i$ued (Sc. 3097. Civ. C.). Lender's Name: - Lender's Address: APPLI('AN DECLARA'I'ION I hcrcty affinn undcr penalty'of perjury'one of the follorvirrg tleclarations: Delnolition Pernrits-Aslrstos Notification Federal Regulalions ('l'itle 40. Parr(r) Required Letter ol' Notification -l csrify that thc fcdml rcaulatiore rcgrding rbctos moval rc not applicablc to thb prcjct. -l csriry thrt I havc Md this applhdion and stdc th.t thc rbovc infomdioo b orff1. I agr lo smply with all City and Comty ordhmc ud Statc lrw3 Ehirg to buiHing consEuctioq od My autlprirc rcprccddiv6 of this City ud County to Gttta rpon thc above mentioned propeay for Applicant or Agent Perrnrtec name Appliances Metal Fire Place Evaporative Cooler Furnace Compressor Misc. Equipment Duct Work Pre-lnsulation lnsulation Smoke Detectors lnstalled Rough Ductwork Vents Toilet Room / Clothes Dryer Residential Ranqe Other Hood Type I Hood Type Il Hood Grease Duct Fire Damper Openings lnstallation F.D. Drop Test Above Hard Lid Above T-Bar Rough Mech. Final Test Meter Release FINAL It zLl fl P+" od,.*97 Rem Etc. qr ol I Number: 1lt 11 7 ?hoat t'x. Da/e/l L t Liccnsem (tu 4tr 4r _ Date:t t /t z//7 +eq