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M ECHANICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDF,R DELCARATION I hercby afftrm undcr pcnalty of lErjury that I m excmpt ftom the Crnlrrcton' Lie[s llw for the following rc8sn (Se.7031.5 Business and Prcfession Codc): Any City or County which rcquires a pcrmit lo onstrucl. 8lls. itr{,row, dcmlish or rcpair any struct[c, prior to its issuece. also rcquires the applicant for such pemit lo lilc 8 signcd ststemnt lhat he or shc is lienwd pursant to thc prcvisions of the Contrctor's Licnsd trw (Chsplcr 9, Comrcing with Scclion 7000 of Division 3 of thc Business 8nd Ppfc$ionsCodc)orlhatheorshcisexcmpttlrefromsrdthebasfuforthcalhgcdcremption. Anyviol8tionofS6lboT03l.5bysny applicant for a pcmit subjcrts lhc spplicsnt to a civil pemlty of rct mrc than livc hundrcd dollus ($50o). _1. as owncr of thc property. or my employees with wages as their solc comlrcnsation. will do the work attd the structure is not intcndcd or offered for salc (Sec.7044. Business and hofessions Code: The Contractor's License law docs not apply lo an owncr of lhc property who huild.s or improvcs thcrcon. and who docs such work himself or herself or through his or hcr own cmployccs. providcd that such improvenrcnts arc not inlended or offered for salc. If. hcrwever. ttrc btrilding or inqrroverEnt is sold within onc )tar of complctkrn, thc Owner Builder will havc thc burdcn of proving that hc or shc did not build or inprove the property for thc purynseof sale). _1. as owncr ol'thc propcrty. arn cxclusively contracting with liccnscd conlraclors lo construct lhc projccl (Sec. 7(A4. Busittcss antl PnlfcssionC<ldc: ThcContractor'sl.iccnscLawclocsnotapplytolnowncrof'propcrtywhohuildsorintprovcslhcrcott. and who conlracls lbr such pnrjccls wilh a Contractor(s) licenscd pursuattl lo lhc Contraclor's Liccttsc Law). -IatttcxcltlpluttderScction-.I}.&P'C.tilrthisrcustllt. l\^a^, }VORK[' RS' CONT PENSA'I'ION DECI ARATION I hcreby alTirnr undcr pcnalty of pcrjury onc of the following dcclarations: I have and will maintain a Certificate of Consent to Self-lnsure for workcrs' compcnsation. a.s provided for by Section 37fi) of thc l.abor Codc, for the performancc of thc work for which the pcrmit is issucd. -l havc and will maintain workcrs' compcnsation insurance. as rcquircd by Section 3700 of thc l.abor Code. for thc performance of the work for which this pcrmit is issucd. My workers' comlrcnsation insurance carricr and policy nunrbcr arc: Policy Number: Expircs: -l certify thal in the pcrformance of the work for which this pcrmit is issued. I shall not employ any pcrson in any manncr so as to becomc subject to the workers' compcnsation laws of California. and agrcc that if I should bccome subject to thc workers' compcnsation provisions of Scction 3700 of thc Latnr Code, I shall. forthwith comply with those provisions.. WARNING: Failurc to sc"curc workcrs' compensation covcrage is unlawful. and shall subject an employer to criminal pcnalties and civil lines up to onc hundrcd thousand dollars (S100.m0). in addition lo thc cost of compensation. damages as provided for the Sc.ction 3076 of thc [:bor Code, inlerest and attonry's fccs. LICENSED CONTRACTOR DECI.^A.RATION I hercby affirm under penalty of pcrjury that I am licenscd under provision of Chapter 9 (comrnencing with Scction 70m) of Division 3 of the Busirrcss and Professions Code. and my licensc is in full forcc ard effcct. License Class: License Number: I)ate: W I hcrcby allirm undcr pnalty of Frjury thot therc is a conslructk n hnding rgcrcy for thc pcrforrorcc of thc work for which lhis lEmil is issued (Scc. 3097. Civ. C.). kndcr's Nrnrc: [-endcr's Addrcss: A PPI ICAT{T DECLA ILITTON I hcreby aflurnunder penalty of perjury orrc of the following declarations: Demolition Pcrmits-Asbestos Notification Federal Regulations (Title 40. Part6) -Required lrtter of Notification -l ccrrify thlr the fcderal rcgulstions Egrding abesloi rcmval re rct applicablc lo lhis prcixl. -l csrify thst I harc rc8d rhis rpplicstion 8nd ststc thql thc .bow infomtbn is cqrcl. I agrc to mmply with all City 8d County otdimres 8nd Ststc L8ws rchting to buiHing @n$ilclio[ ard hercby aulhoria rcpresntrrircs of thi! City md County to cnts qEn the abovc mcntioned propcrty for inspcction pur[xlscs. Applicant or Agcnt Signutur"' t D"t", Pcnnitcc nanrc (nrint): Appliances Metal Fire Place Evaporative Cooler Furnace Compressor [tIisc. Equipment Duct Work Pre-lnsulation lnsulation Smoke Detectors lnstalled Rough Ductwork Vents Toilet Room I Clothes Dryer Residential Ranqe Other Hood Type I Hood Type II Hood Grease Duct Fire Damper Openings lnstallation F.D. Drop Test Above Hard Lid Above T-Bar Rouqh Mech. Final Test Meter Release I ^l FINAL tZtl2)l)t\ nr t4rffi Notgs, Remarks, Etc t ?/, 17,0 N0 ftntf t,Vâ‚¬TL D\rnc L +fT I u Owner:_ Carrier: Date:_Applicant: + ContractorK