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M ECHAN ICAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI.CARATION <br />I hacby allirm undr pculty of pcrjury that t m cxcmpt from thc Contracton' Licm Law for thc hllorving r@n (Se.70-11.5 <br />Buine and Profcssion Code): Any City or County which rcquirc a pcruit to coGtruct. altc. improvc dcmlish or rrpah uy <br />structuc. prior to its iwca also rcquirc thc applicmt for such pcmit to filc a sign(d ststmot thd hc or shc b licmcd pmant <br />to thc prcvisioE of thc Contrrctor's Licmscd krv (Chapts 9. Commocing with Sction 7000 of Division 3 of thc Busirc ud <br />Prcfsions Codc) or thst hc or shc is cxmpt thccfrom ild thc bris for thc allcac{ amplion. Any violation of Sc{ion 7031.5 by any <br />applicantforapemitsubjetsthc applicsnttoscivilpmltyofnotmrcthefivchundrcddollm(3500). <br />-1. <br />as owner of the property.or my employees with wages as their sole compensation. willdo the work and the structure is not <br />intcndod or offered for sale (Sec.7M4. Business and hofessions Code: The Contractor's Licensc Law does not apply to an owner of <br />the pnrpcrty who b,uilds or improves thereon. and who does such work himself or herself or through his or her own cmployees. <br />provided that such improvonents atc not intendcd or offerod for sale. I[, however. the building or improvement is sold within one year <br />of complaion. the Ourner Builder will have the hrden of proving that he or she did not build or improve the property for thc purposeof <br />sale). <br />--1. as owner of the prop€rty. am exclusively contracting u'ith licensed contractors to construct the project (Sec. 7M4. Business <br />and Pnof€ssion Code: The Contractor's License [-arv does not apply to an oivner of property who builds or improves thereon. <br />and rvho contracts for such projects s'ith a Contraoo(s) licensed pursuant to the Contractor's Liccnse Law). <br />_l am exempt undcr B. & P.C. for this reason. <br />l)itlt'Onner: <br />\\'0 ltK l'.RS' ('()i\l I'IlNSA'l'l()N <br />t)r.('l,Alt^'l'loN <br />onc ot'thc lirllorr irrg tlcclarations:I hereby alTirm under poralty of perjury <br />-l <br />have and rvill maintain a Certificate of Consent to Self-lnsure for rvorkers' compensation. as provided for by Section 3700 of the <br />Labor Code. for the performance of the rvort for rvhich the permit is issued. <br />Fthe <br />have and rvill maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the performance of <br />w'ork for rvhich this permit is issued. My rvorkers' compensation insurance carrier and policy number are: <br />l r l'it cs <br />-l <br />cerrify rhat in the performance of the work for rvhich this permit is issued. I shall not cmploy any person in anyrninner <br />so as to become subject to the rvorkers' compensation laws of California. and agree that if I should become subject to the <br />workers' compensation provisions of Seclion -1700 of the Labor Code. I shall. forthrvith comply rvith those provisions.. <br />\VARNIN(I: Failure to secure rvorkers' conrpensation is unlarvful. and shall subject an anployer to cf;minal penalties and <br />compensation. damages as provided for thecivil fines up to one hundred thousand dollars in addition to the cost of <br />Section Labor Code. interest and fees. <br />\ <br />LICENSED CON'TRACTOR <br />DECLARA'I'ION <br />I hereby affirrn under penalty of perjury that I arn licensctl under provision of ('hapter 9 (conrrncncing rrith Section 7000) of Division -1 <br />of the llusiness and Professions Code. and my liccnse is in firll ftrrce and effect. <br />Ltp )lcbt QsuLicense <br />( <br />CONSTRUCTION LENDING AGENCY <br />I hmby affm undc pcosty of pcjury thrt rhtr is a con$ructbn kndiog ag6cy for thc pcfomre of thc work for which this pqmit b <br />ir{uc{ (36. 3097. Civ. C.). <br />l.entlcr's Narne: <br />Lender's Address: <br />A PPI,I('AN'T DE(' LARA ION <br />I hetc\ affinrr urrder pcnalty of perjury one of tlre follorving declarations: <br />l)crnolition l)crrnits-Asbestos Notification l;ederal Rcgulations ('l'itle 40. Part6) <br />llcquircd l,etlcr of Notification <br />- I cqtify that (he Gdsal regulations rcgtrding ashcstos rcmoval arc not applicoble to this prrrjet. <br />I colify lhd I have read this applicatioo ild stalc lhat lhc ahrrc infornralion is cord. I alre to comply s'ith all City and ('ount1' <br />ordinancs and State l,arvs relating to building constnrclion. md hucb;- authorize reprsfllaliv6 oflhis Cily and ('ounty to mlq uF$n the <br />above mentioned propefly for <br />Applicant or Agent <br />Pennitee narne <br />*,., t\ti tl1 <br />Appliances <br />Meta! Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors Installed It -14- lq rlP=J f6> <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type ll 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.I z-t4 -19 <br />Final Test <br />Meter Release / v",2) <br />FINAL lu-l 1-q <br />Notes, Rema rks, Etc. <br />.*". B6nCrhtrt^rE <br />Poricy *,,*,C 6f 5b \u\ 22\s\rq[zr> <br />u I