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M ECHANICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION t h6eby aftum uod6 pcruty of pGjury that I m cxmpt from thc Contr.ctoB' Lictrsc law for thc following rmn (56.7031.5 Bwins and Prcf*ion Code): Any City or County rvhich requirB 8 Fmil to sGtruct. altc, imprcve &mlish or rpair ay structuc. Fior to its ismc. also requirB thc applicmt for such pcrdt to frlc I signcd stalmat thrr hc or slE b licqEâ‚¬d pmart to thc fovisioru of thc Contractor's Liccnscd Law (Chapts 9, Commcncing with Sstion 7000 of Division 3 of thc Buine md Prcfsions Codc) or that hc or she is dempt thq.ftom ud thc besis for thc allcgcd cxmptiotr. Atry violation of S6{bn 7031.5 by my applicant for a pmit subjets thc applicant to a civil penalty of not morc thm fivc hundrcd dollm ($500). -1, 0s owner of the property. or my employees with wages as their sole compensation. willdo the work and the structure is not intendod or offered for sale (Sa.7M4. Business and hofessions Code: The Contractor's License Law does not apply to an owner of the property who hrilds or imp,rovâ‚¬s ther@n. and who does such work himself or herself or through his or her own employec. provided that such impovanrents arc not intended orofferod for sale. lf. horvwer. the building or impnovement is sold within one ]rar of completion" the Orvner Builder will have the burden of proving tha he or she did not buiH or improve the propaty for ttrc purposcof sale). -1. as o\rner of the property. am exclusively contracting with licensed contraclors lo conslruct the project (Sec. 7044. Business and Profession Code: l'he Contractor's License Larv does not apply to an owncr of properly rvho builds or improves thereon. and who contracts for such projects with a Contracto(s) licensed pursuant to the ('ontractor's License Larv). -Iarne.\emptunderSection-.B.&P'C.forthisreason.l)irte WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one ofthe follorving declarations: -l have and will maintain a Certificate of Consent to Self-lnsure for workers' conrpensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which the pcrmit is issued. -l have and will maintain workers' compercation insurance. as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Policy Number: Expires: -l certify that in the performance of the rvork for which this permit is issued. I shall not onploy any person in any manner so as to become subjert to the workers' compensation laws of California. and ag,ree that if I should become subjcct to the workers' compensation provisions of Section 3700 of the Labor Code, I shall, forthwilh cornply with those provisions.. WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subject an anployer to criminal pemlties and civil fines up to onc hundred thousand dollan ($100.000). in addition to the cost of compensation, damages as provided for the Section 3076 of the l-abor Code. interest and attorney's fees. Date: Applicant: I ICFNSEN CONTRAC'TOR DECI..ARATION I hereby aflinn under penalty of perjury that I arn licensc<l under provision ofChapter 9 (contmencing with Soction 7000) of Division 3 of the Business and Professions Code, and rny license is in fiull force and elfect. License Class: License Number: l)atc: ('orttrrclor; W I hady alfm udq p@rlty of pqjury that th@ i! . onstructbtr knding agacy fur thc pqfomcc of thc mrk 6r which this p6mit b issucd (Se. 3097, Civ. C.). Lender's Name: APPI ICANT DF'CI ARATION I herdD/ affirm under pcrialty of perjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) -Required Later of Notification -l c6ti& thd thc fcd6d rcgulatiou rcgading cbatos moval de not applicsblc to this prcjet. -l stiry tha I havc rcsd this spplic*ion {d statc that thc sbovc infomstiotr i! cotrEl. I rgc to @mply with all City ud Couty odirc md Statc Lrw rclatilg to building coEtructioc atd h6rby uthorirc reFMtdiG of this City md Couty to atq upol thc abovc mtionod pmpqty for irepction purpos Applicant or Agent Signaturq f\atc. Appliances Metal Fire Place Evaporative Cooler Furnace Compressor Misc. Equipment Duct Work Pre-lnsulation !nsulation Smoke Detectors lnstalled Rough Ductwork Vents Toilet Room / Clothes Dryer Residential Range Other Hood Type I Hood Type ll Hood Grease Duct Fire Damper Openings lnstallation F.D. Drop Test Above Hard Lid Above T-Bar Rough Mech. Final Test Meter Release ., I ,A ,1 {A F!NAL tll'Mpltl fillrurc|,4v Notes, Remarks, Etc.I r /?^WerVd ca -n) /rjtffiw Lender's Address: Pennitee narne (print):