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M ECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby affrm undcr lEn&lty of pcrjury thal I m exempt fmm the ContnctoB' Licens kw for the following rc&$n (Ss.7031.5 <br />Busincss and Prcfcssion Cndc): Any City or County which rcquircs a fsmit to onstrucl. sltq, imprcrc, dcmlish or quir rny <br />structurc. frior to iti issure. als rcquires the spplicsnt for such Fmit to lilc 8 sigred stalemnt that he or shc h liccnsd pusrtil <br />to thc prcvisions of thc Conlrrctor's Licu*d taw (Chspts 9. Commrcing with Setion 7000 of Divisiotr 3 of Ihc Busircss and <br />PDfcssknsCode)orthsthcorsheiscxemplllmfromandthebasisfortherllegcdercq{ion. AnyviolrtionofSelbtrT03l.5byrny <br />applicant for a Jrcrmit subjsts thc spplicant to a civil pentrlty of not morc than fivc hundrcd dollus ($500). <br />_1. as owner of thc property. or my employecs with wages as their solc compensation. will do thc work and thc slruclurc is not <br />intcndcd or offercd for salc (Ser.7044, Business and Profcssions Codc: The Contraclor's Liccnse law does nol apply to an owner of <br />the propcrty wtro builds or improves thcrcrn. and who does such work himself or hcrsclf or through his or her own employees. <br />providcd that such improvcnrnts arc not intended or offcrcd fnr salc. lf. however. thc huilding or improvenrcnt is sold within one )aar <br />of cornphtion. the Owner Builder will have the burden of proving that hc or shc ditl nol build or impovc thc propcrty for thc purgnsc of <br />sale). <br />-1. <br />as o\\'ncr of thc proprly. arn cxclusivcly conlractilrg rvith liccrrscd corrlraclors lo conslntcl lhc projcct (Scc. 7(A1. Busincss <br />and who conlrilcls lirr such projccls with a Corrlraclor(s) liccrrsctl pursu:urt to lhc Corttraclor's l.iccnsc Law). <br />-latttcxctIlpluntlcrScctiott-.I].&P.C.litrthisreastltl.l):rlt' ( )s ner <br />WORKERS' CONI PENSA'IION <br />DECLARATION <br />I hcrcby afllrrn undcr pnalty of perjury orrc of thc frrlkrwing dcclarnlions: <br />-lhavclrxlwill <br />nuintainaCcrtilicalcofConscnttoSclf-lnsurcforu'orkcrs'cornpcrrsalion.as providcdlorbyScctionST00ol'thc <br />Latxrr Codc. lbrthe pcrlirnnance of thc work lbr which lhc'perruit is issticd. <br />-l <br />havc and will nraintain workcrs'conrpcnsation insurarrcc. as rcquircd hyScction 37fi)of lhc l.aborCode. lbrlhc Jrcrfornunccof <br />lhe work for which this pcrnrit is issucd. My workcrs' conrpcnsatiort insurance carricr and Jmlicy nutttbcr arc: <br />Policv Number: Exoires: <br />_l certify that in thc pcrforrnancc of thc work firr which this pcrrrrit is issucd. I shall not ernploy any pcrson in any manner <br />so as lo hecomc subjcct to thc workcrs'conrpensation laws of Calif'ornia. and ngrcc that if I should hccotttc subjcct to ltre <br />workcrs' compensation provisions of Section 37U) of the Latnr Codc. I shall. forthwith conrply with those provisions.. <br />WARNING: Failurc to sc.cure workcrs' compensalion coveragc is unlawful. and shall subject Bn cmployer to oiminal penaltics and <br />civil fines up to onc hundred thousand dollars ($100.fin). in addition to the cost of comlrcnsation. damages &s provided for thc <br />Section 3076 of thc Labor Codc, interest and attorney's fecs. <br />Applicant: <br />LICENSED CONTRACT(IR <br />DECLARA'I'ION <br />I hcrchy tl'linn undcr pcnulty of pcrjury that I arn liccnscd undcr provision ol'Clraplcr 9 (cornnrcncing rvith Scction 7(XX)) of Divisiorr .1 <br />ol' tlrc Business antl l'rol'cssions Corlc. ard rny liccrtsc is in full lirrcc atxlcfl'ccl. <br />License Class: License Number: <br />Dele: Conlraclon <br />coxstnucrron lrrotric,rctncv <br />I hcrcby allirm undcr Fnillry of pcrjury lhd llErc is u c$nslrucrion hoding lEctrcy li)r lhc psformancc oflhe work ltrr which lhis Frcrmit is <br />issucd (Ss. 3097. Civ. C.). <br />lrndcr's Narnc: <br />Lender's Addrcss: <br />APPI I CAN'I' DI.'CLARAI'I()N <br />I hcrchy irlllrrrr untlcr grcrralty of pcrjury ottc of thc lirlkru'ing dccluratiotts: <br />Dcnxrlitiorr Pcrnrils-Asrouslos Notil'icatiorr Fctlcral Rcgulations ('l'itlc Atl. Parr(rl <br />-Rcquircd <br />Lcttcr ot'Nolification I <br />-l <br />ccrtily thill lhc lcdcrnl rcglulalions rcgudir8 ashcsk)s rctrf,)val{tc nol applicuhlc k) this preia1. <br />_l ccnify thot I have rcd this applir'illion and slalc lhill lhc ahorc inlilrnBlion is core1. I lEre k, (nnply with all Cily and County <br />ordinnrecs and Stllc lnws rclating to huiklitrg conslrucli([. and hcrchy iluthorizc rcprcscnlalivcs oflhis City and Counly to cnler ulnn lhc <br />ahovc [Enlioncd pmpcily for inspccliu purlnscs. <br />AJlplit'trlrt ()r /\gcnl Siurrirlttrc:I\..r,'. <br />l'cr rrrilt't: rrlrnrc ( l)l int ): <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />!nsulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type Il Hood <br />Grease Duct <br />Fire Damper <br />Openinqs <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release I <br />FINAL )\=71-(/l YPfrfr <br />Notes, Remarks, Etc.I <br />C