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M ECHANICAL.I NSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hoeby affm uodq pcmlty of pqjury thd t m exmpt frcm thc ContrrctoE' Licw trw for thc following l@n (56.7031.5 Buincs ad Profsion Codc): Any City or Coudy which rcquhc a pomit to erotrucL attE impovq danolish'or rtpoir oy struc{[c. prbr to its iswcc. also rcquirc thc applicut for such pqmh to filc a signcd std@ot thd hc or shc b licmscd pmwt to thc provisioB of thâ‚¬ Contretor's Liccnscd kw (Chrptq 9, Commcing with Setion 7000 of Division 3 of thc Bsiosdod Prcfcsiore Codc) or that hc or shc is qmpt th@fiom ed thc basis for thc allcacd cxmption. Any violstion of S4lion 7031.5 by any applicst for 8 pennit subjats thâ‚¬ applicant ro a civil paalty of not mrc tho fivc hun&cd dollrs ($500). _1, as owncr of the Fopcrty, or my employce with wages as their sole compersation, wi[ do the wort and thc $nrturc is not intcndod or offered for sale (Sec.7044, Business ard Profcsions Code: The Contractor's License l-aw does not ryply to an own6 of the propcrty who hrilds or improves theron, and who does such work himself or herself or through his or her own employees. provided that such improvanents 8c not intendod or offcrcd for sab. I[, howerrer. the building or imprcvement is sold within one ]car of completioru the Owner Buildâ‚¬r will have the burden of provfurg tlra he or shc did not build or improve the propcty for the purpose of sale). -1. olr owner of the propcrty, anr cxclusively contracting with licensed contracton to construct the project (Scc. 7044, Buincss and hofcssbn Code: The Contractor's License Law docs not apply to an owner of propcrty who builds or improves thereon, and who contracts for such projects with a Contracto(s) licerued pursuant to the Contractor's Licensc l-aw). -l am exempt under Section-, B. & P.C. for this reason. TOS6EESS.AI4EENSAIION DECI.ASAIIAN I hoeby a[Iim undo pcnaltyof po'jury onc ofthc following delaatiore: *alhaw{tvillrointairaCcrtificateofcoMttoselfJrourcforworkm'compquation,r prcvidcdforbySclion-lTClofthe Labor Code, for thc pcfonmcc ofthc wort for which thc psrnit is isucd. 9/lrhave and will mainrain workers' compensation insurance, as requircd by i the work for which this pe'nnit is issued. My workers' compensation insurance Section 3700 of the l-abor Code, for the ,carrier and policy number are: ncrfonlancc of "/r/ zozzporicy N"^v"r, ?6O co Ddl/6 2 /t Expires: _l certi& that in the performance of the work for which this permit is issued, I shall not qnploy any person in any manner so as to become subject to the workers'compensation laws of California, and agiee that if I should become subject to the workers' compersation provisions of Section 3700 of the Labor Code, I shall. forthwith comply with those provisions.. WARNING: Failure to secure workers' compcnsdion covoage is unlawful, and shall subject an anplopr to crimind poahics and cMl fines up to one hundred thousand dollars ($100,000), in addition to the cost of compensation, damages as provided for the Section 3076 of the l-abor Codg interest and attorney's fc6. orrc, d/f0/>/ Appucanr S-A *t.'/.r-a-^-<- LICENSED CONTRACTOR DF'.rLAIL{TION I haeby affrm under penalty of pcrjury that I anr licâ‚¬nsd undcr provision of Chapto 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my [icense is in full force and effect. 4q(o24l.icense Numbcr: W I hcby affm unda pcnatty of pojury tha th@ i! a ou$rudbn loding agcy for thc psforrc of ttc wo* br vtich thb pmn b iscd (Se. 3097, Civ. C.). l.cnder's Name: lrnder's Address: A,*LICANT DECLARAT I hereby afnrm under penalty of perjury one of the following declarations: Dernolition Permits-Asbestos Notification Fcderal Regulations (Title 40, Part6) -Required Letter of Notification _l cefli& that the federal regulatioru rcgarding asbcstos removal are not applicable to this project. $!-rcâ‚¬rtiry that I have read this application and state that the above information is correcl. I agrec ro compty ordinances and State [aws relating to building constn"rction, and hereby authorize represcritatives of this City with all City and County and Cormty to exter upon the above mentioned propâ‚¬rty for inspection Applicant or Agent Pennitee name o^,", e/rl y'zt Appliances Metal Fire Place Evaporative Cooler Furnace Compressor Misc. Equipment Duct Work Pre-lnsulation lnsulation Smoke Detectors lnstalled Rouqh Ductwork Vents Toilet Room / Clothes Dryer Residential Range Other Hood Type I Hood Type II Hood Grease Duct Fire Damper Openings lnstallation F.D. Drop Test Above Hard Lid Above T-Bar Rough Mech. Final Test Meter Release l I I r - t),t FINAL J ta( \q l7/l bI\ Notes, Remarks, Etc.I 4_ o*", {/il/tt co.o,ao,, fatltotiull Co-*t<ol-\s Ct+?- Y lCf .-/an lO.ta,.-