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M ECHANICAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION <br />I hmby affm undc pcaalty of pcrjury that I m qcmpr fiom thc Contractorc' Licene Lrw for the following wn (Scl7o3lii <br />Buincs sd Profsion Codc): Any City or Coutrty which rcquirc a pcmh to corutruct. akq. improvc, damlisl or rtpoir aS <br />structur, prbr to ias issumcc. also rcquirs thc applicot for such pcrmit to filc a signcd statoot that hc or slE b licccd ptNut <br />to thc provisioE of thc Contractor'! Liccnrcd t:w (Chapta 9. Comcncing with Sction 7000 of Division 3 of thc Busins ud <br />Prcfsiom Codc) or that hc or she is qcmpt thq€from md thc basis for thc allcged emptiotr. ADy violation of Sclion 7031.5 by ey <br />applictrt for 8 pcrmit subjcts thc applicmt to a civil pmlty of not morc the livc hun&ed dollus (5500). <br />-1. <br />as owner of the property. or my employees with wages as their sole compensation, will do the work and the stnrfirc is not <br />intcnded or offered for sale (Sc.7044. Business and hofessions Code: The Contraclor's Liccnsc [-aw does not apply to an owner of <br />the propcrty who builds or improves theron" and who does such work himself or herself or through his or her own employees. <br />provided that such funprovanents are not intended or offerrod for sale. l[, howwer. the building or improvcmcnt is sold within one ]Ezr <br />of complction, the Orvner Buildcr will have thc hudo of proving tha he or she did not build or imp,rove the propoty for thc purposc of <br />sale). <br />-1, <br />Bn owner ofthe propcrty, 8rl cxclusively contracting with ticeosod contracton to construct the project (Sec. 7044, Business <br />and Proftssion Code: The Contractor's License Law does not apply to an owncr of property who builds or improvcs thereon, <br />and who contmcB for such projects with a Contracto(s) ticenscd punuart to the Contractor's Liceosc l-aw). <br />-l <br />am exempt under Scction-, B. & P.C. for this reason. <br />l)ul c: <br />WORKERS' CONTPENSATION <br />DECLA]TATION <br />I hereby affirm under penalty of pojury one of the following declarations: <br />-I <br />have and will maintain a Certificate of Conscnt to Self:lnsure for workers' compensation, as provided for by Section 3700 of the <br />Labor Code. for the performance of the work for which the permit b issued. <br />-l <br />have and will maintain workers' compensation insurancer as required by Section 3700 of the Labor Code, for the pcrfornrance of <br />the work for rvhich this permit is issuod. My workers' compensation insurance carrier and policy number are: <br />-ll a 0-T [)n "\4(.-,;at \r-e-s T PS-C o <br />Policy \r-J E ,7 I a lo'JG - Zc, l9 <br />_l cerri& that in the performance of the work for which this permit is issued. I shall not employ any person in any manner <br />so as to become subject to the workers'compansation laws of California. and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the t-abor Code I shall. forthwith comply with thosc provisions.. <br />WARNING: Failure to sccure workers' compensation coverage is unlawful. and subject an crinrinal penalties and <br />civil fines up to one hundred thousand dollars ($100,000). <br />Section 3076 of thc Labor Code interest and anorney's fees. <br />the as provided for the <br />t <br />DECI ^ RATION <br />I hereby aflirm under penalty of pcrjury that I am licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code. and my license is in full force and effect. <br />b jw <br />License , <br />F 2 5 1 <br />CONSTRUCTION I T'NDING AGENCY <br />that there is a construction lending agency for the performance of the work for which this pennit is <br />Lender's Address: <br />,rr tcANr "".LARATI hereb,, affrnn under penalty of perjury one of the follorving declarations: <br />Demolition Permils-Asbestos Notification Fedcral Regulations (Title 40. Part6) <br />-Required <br />Lrtter of Notification <br />-l <br />certi& that the federalregulations rcgarding asbestos removal are not applicable to this projed. <br />I agree to comply with all City and County <br />of this City and County to crter upon the <br />above mentioned property for <br />Applicant or Agent 1 <br />Pennitee nzune v\ <br />and state that infonnation is <br />g-- I <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />Insulation <br />Smoke Detectors lnstalled <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />Installation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release ltr <br />FINAL Q-L,12 t/l (LC tc.vsllg -Lrl <br />Notes, Remarks, Etc. <br />-> <br />a <br />L <br />,lr,.- <br />Contractor:$-!.-\ <br />il <br />o6Y(a U Lb