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MECHANICAL.INSPECTOR RECORD a APPROVALS DATE ID/SIG COMMENTS OWNER BT'ILDER DELCARATION I hcrcby affrm under pcnslty of perjury lhal I u clempl frcm ttE ContrrcloB' Lieosc kw for the following re&sn (Ss.7031.5f Business and Profcssion Code): Any Cily or County which rcquircs s Fmil to o[druct, 8ltq, imprcrc. demlish or Epofu uy stffturc. Fin to its issrre. alrc rcquircs thc applicant for such pcrmit to file 8 signcd stalcrcnl lhql he or shc is liccnsd puisunt to the Eovisions of thc Contractor's Licnscd [Iw (Chlptcr 9. Comrcncing with Section 700O of Division 3 of lhe Busincss snd PrcfessionsCode)orthsthcorshehcxetrptthercfrcmandthebssisforthcallcgcdcrcmption. AnyviolstiooofSslionT03l.5bysny applicsnt for a pcmit subixts the applicsnt to a civil pcmlty of not mrc than five hundrcd dollus ($50O). _1. as owncr ()f thc propcrty. or my cnlployccs with wagcs as lhcir solc conrpcnsation. will d<l lhc work atd thc sln.rc'lurc Ls not intcmled or ofl'ercd firr salc (Sc.c'.7(X4. Busincss and Pnrf'cssions Codc': '[hc Contruclor's Liccnsc Law docs nol apply lo an owner o[ thc proprty who builtls or improves thcrcon. &nd who dtrcs such u'ork himsclf or hcrsclf or lhrough his or hcr own ctnployccs. providctl that such irnprovcnrnts arc not intendcd or offiercd ttrr sah. ll. howcvcr. thc huilding or inprovctncnl is sokl within onc yciu ot'conrplction. thc Owncr Buildcr will havc thc burdcn of proving that hc or shc did not huild or inrprovc lhc propcrty lirr thc purporc o[ salc). -1. as owncr of thc propcrty. iltncxclusivcly conlracting with liccnscd conlractors to conslruct lhc pnli'ct (Scc. 7()t4. Ilusincss and PnrtbsskrnCodc: 'l'hcContractor'sLiccnscLawdocsnotapplyloanowncrofpropcrtywhobuildsoritnprovcsthcrcon. ancl who contracts for such projccts with a C<lrttraclor(s) liccnscd pursuant lo thc Contractor's Liccnsc Luw). -lantcxctnplundcrSection-.B.&P.C.ltlrthisrcason.Il.,r^. WOIIKERS' COM PENSATION DT'CLARATION I hercby affirnr undcr penalty of perjury one of the following declarations: -l have and will maintain a Certifhate of Consent to Self-lnsure for workers' compensation. as providcd for by Section 3700 of thc l-abor Ccde. for the performance of the work for which the permit Ls issued. -l havc and will maintain workers'compensation insurancc. as by Scction 3700 of thc labor Codc, for thc performance of the work for which lhis pcrmit is issued. t\t Lr and plicy number are: I l3zLPolicy _l ccrtify that in thc pcrformance of the work for which this prmit is issued. I shall not enrploy any person in any manncr so as to bccornc subict to the workcrs'compcnsation luws of California, and agrce that if I should becomc suhict to thc workers' comJrcnsation provisions of Section 3700 of the [:bor Codc. I shall. forthwilh comply wilh thosc provisions.. WARNING: Failurc to srcurc workcrs' compcnsation covcragc is unlawful. and shall subjcct an cmploycr to criminal Jrenaltics and civil fines up to one hundrcd thousand dollars ($100.fin1. in addition to lhe cost o[ compensation. damages as providcd for the Scction 3076 thc [:txlr Code. interest and attorney's fccs. I)E('I,AR,\'I'I()N I hercby affirm undcr penulty of pcrjury that I am liccnscd undcr provision of Chaptcr 9 (commcncing with Scctinn 7fin) of Division 3 of thc Busincss and Professions Codc. and my liccnsc is in full forcc ard effcct. lo3?RLiccnseNurnhcr: c'( )NS'I'R l-lC'l'l( )N l,llN l)lN(; A( ; l,:N('l' I hercby affirm undcr lEnslty of pcrjury that therc is s mnstructk n bnding 8gercy for thc Faformrcc of thc work for which this pcmil iB issucd (Scc. 3097. Civ. C.). kndcr's Nanrc: Lendcr's Addrcss: ,pLrcANT trECI ^ R I hercby aflirrn undcr penalty of pcrjury onc of thc following dcclarations: Dcnrolition Pcrnrits-Ashcstos Notificalion Fcdcral Rcgulations (Titlc 40. Part6) -Rccluircd Lctlcr of Notificalion I t certify that the fcderal regulations rcgarding asbcstos removal are not applicable to this projcct.r{ I certify that I have read this application and slatc that the above information is correct. I agrce to comply ordinances and State Laws relating to building construction, and hereby authorize representatives of this City with all City and County and County to cntcr upon the abovc mentioncd pro;,crty for inspcction Applicanl or Agent Pcrrnilcc nrnrc Date:7n/t Appliances lVletal Fire Place Evaporative Cooler Furnace Compressor It/isc. Equipment Duct Work Pre-lnsulation !nsu lation Smoke Detectors lnstalled Rough Ductwork Vents Toilet Room I Clothes Dryer Residential Ranqe Other Hood Type I Hood Type ll Hood Grease Duct Fire Damper Openings lnstallation F.D. Drop Test Above Hard Lid Above T-Bar Rouqh Mech.1,/iz/t.,?\ q\ Final Test Meter Release ^/ /fi A FINAL "7;t/w I*brt4 "ffi6 Notes, Remarks, Etc.I _ Owner: "",". 1f t1f lL Dale:_q contracto.'kFn(-l I c\ I