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M ECHANICAL.INSPECTOR R ECOR D APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hercby affrm undcr pen8lty of perjury that I m excmpt fiom thc Contnc{on' Liens Lrw for thc followitrg rc.sn (56.7031.5 Business and Profcssion Codc): Any City or County which rcluircs I permit lo soslrucl, alt6, imprcve, &mlish or qEir my struc{urc, prior to its issusce. rlso rcluircs thc applicant for such lErmit to filc s signed starcmnt that hc or 3he is licenEd pur$ot to thc Fovisions of the Contnctor's Liensd lrw (Chsptcr 9, Comming with S6lbn 7fi)O of Division 3 of thc Busincss snd Prcfcssions Codc) or thoa hc or slE is crempt thcrcfrom ed rhe bsis for thc allegcd cxcmption. Any vblstion of S6tbn 703 I .5 by any Epplicsnl for a permia subjcas the applicant to s civil pemlty of ml mrc thu live hundrcd dollars ($50O). -1. as owner of the propcrty, or my cmployees with wagcs as their sole compcnsation, willdo the work and the stnrturc is not intendcd or offered for sale (Sec.7044. Busfuress and Profcssions Code: The Contractor's License l.aw does not apply lo an owncr of thc proFrerty who builds or improrcs thereon. and who does such work himsclf or hcrself or lhrough his or hcr own employccs. provided that such improvenrcnts are not intended or offcred for salc. lf. however. the building or inproverrnt is sold within one )rar of complction. the Owncr Builder will have thc burdcn of proving that trc or shc did not build or improve tlre propcrty for the purlnsc of sale). -1. as owncr of thc property, ant cxclusivcly contracting with liccnsed conlraclors lo construct the project (Sec. 7W. Busincss arrl Profession Code: The Contraclor's Liccnse Law docs not apply lo an owner of property who builds or improvcs thcrcon. and who conlracts for such projccts with a Contracto(s) liccnsed pursuBnt to the Contractor's Liccnse Law). -l am undcr B. & P.C. I hcreby affirm undcr pnalty of Jrcrjury onc o[ the following declarations: -l havc and will maintain a Certificale of Consent lo Self-lnsure for workcrs' compensBtion, as provided for by Section 3700 of the I-abor Codc. for the pcrformarrce of thc work for which the prmit is issued. _l havc and will maintain workers'conrpcnsation insurancc. as rcquircd by Scction.1700 of thc l-abor Codc, for thc pcrlbrrnancc of thc work for which this perrnit is issucd. My workcrs' comlrcnsation insurancc carrier and plicy number arc: Carrier: Policv Number: Exoircs: _l certify that in thc ;rcrformancc of thc work for which this permit is issucd. I shall not employ any person in any manncr so as to bccomc subjcct to thc workcrs' compcnsation laws of California. and agrcc that if I should become subject to the workcrs' comJrcnsation provisions of Section .1700 of thc ktnr Codc. I shall. forthwith comply with thosc provisions.. ) a WARNING: Failurc to sccurc workers' civil fincs up to onc hundred thousand Scction 3076 of thc l^atnr Codc. intcrest r compcnsulion is unlawful. and shall subject an employcr to criminal linalties and compensation. damages as provided for thein addition to the cost of and LICT'NSED CONTRACruR DFCLARATTON I hcrcby af'frnr undcr pnulty of prjury thal I am liccnsc'd undcr provision of Chaptcr 9 (corttrtrcncing with Scction 7(XX)) of Division .l of the Busincss and Professiorts Codc. and nry liccnsc is in full frrrce and eft'cct. Liccnse Class: License Number: I)ale: CONSTRUCTION I -T'NDING AGI'NCY I hcrcby lflirm undcr Fnolty of pcrjury th[t thcrc is o snstructk n lcnding agcncy for thc pcrfomrcc of lhc work for which this prmit is issucd (Sa. 3097. Civ. C.). bndcr's Namc: [-cndcr's Addrcss: APPLTCANT DFCLARATION I hcrcby affnm undcr penalty of pcrjury onc of thc following declarations: Dcrnolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) -Rcquired Lrttcr of Notification _l certify that thc fcdcral regulations rcgarding asbcstos rcmoval rrrc nol applicable to this projcct. -l ccrtify that I havc read this application and slate lhat thc above information is corrccTTfpircrto comply with all City and County ordinanccs and State [:ws rclating huilding construclion. and hercby aulhorizc rcprcsenlatives of this City and County lo cnler uJxrn thc abovc nrcnlioncd propcrty for Applicant or Agcnt Pcrrnitcc narrrc h,", tt f blLo Appliances Metal Fire Place Evaporative Cooler Furnace Compressor It/isc. 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 Mood Grease Duct Fire Damper Openings lnstallation F.D. Drop Test Above Hard Lid Above T-Bar Rough Mech. Final Test Meter Release FINAL 1-A-A til ID Notes, Remarks, Etc \ \-/ o* I