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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDEN, DELCARATION <br />I hcrcby affum under lEnalty of perjury that I m exempt fmm the ContrsctoB' Liens t{w for the following mtsn (Ss.7031.5 <br />Busircss ard Prcfcssion Code): Any City or Couoty shkh rcquircs a tmit to @nstrucl. sltr imprcvc, dcmlish or rcinirtny <br />slruclurc. lrior lo ils isswe. also requircs thc applicanl for such lEmit to filc a signcd st8tcrent that he or she h licnsd punuant <br />to the pmvisions of the Contrclor's Liensd Lrw (Chsptq 9, Comrcing vith Setion 7(x)0 of Divisior 3 of thc Busircss and <br />PmfessionsCode)orthathcorsheiscxerptthercfromandthebasisforthe.llegcdexemption. Anyviol.tionofsstbnTO.jl.5byany <br />applicsntforrpermitsubjc{tsthe lpplicantto.civilpcultyofnotmrcthanfive hundrcddollus($500). <br />-1. <br />as owner ol'thc proJrcrly. or my crnployccs with wagcs as thcir solc conlpensaliorr. willdo the work and lhc structurc is not <br />intcndcd or ollcrcd for salc (Se'c.7(X4. Busincss and Prol-cssi<lns Crxlc: 'l'hc Contractor's [-iccnsc l-aw docs not apply to an owncr of <br />I hc Jlropcrly who buikls ()r inrprovcs lhcrcort. und who clocs such work hinrsclf or hcrscll' or throttgh his or hcr own cnrployccs. <br />providcd lhat such inrprolcrrrcnls arc not intcndcd or otTcrcd ltrr sak'. lf. horvcvcr. thc buikling or inprovcrrnl is sold within onc yc:r <br />ol'conrplction.lhc Owncr Buildcr will havc thc hurdcn of pnrving lhat hc or shc did not huikl or irnprovc thc pnlJrerly for lhc purprscof <br />salc). <br />-1. <br />aso\r,ncrol'lhc propcrty. arnexclusivelyconlracting with liccrrscd contraclorstocorrslrucl lhe projcct (Scc. 7(44. Busincss <br />and PnrtbssionCoclc: 'l'he Contractor's [-iccnsc Law docs not applylo ano$'ncr of propcrtywho builds or improvcs thcrcon. <br />and u'ho conlracts tirr such projccls with a Conlractor(s) liccnscd pursuant lo lhc (-'orrtraclor's Liccnse [-aw). <br />_l arrt cxcnrpl urrdcr Sc-ction_. ll. & P.(1. for lhis rcasorr. <br />I ):rlt'J lu.nor. <br />WORKERS' COMPF'NSATION <br />DECLARATTON <br />I hercby affirm under Fnalty of pcrjury onc of the following declarations: <br />-l <br />havc and will maintain a Certificale of Consent to Self-lnsure for workers' compcnsation. as provided for by Section 3700 of the <br />of <br />-l <br />certify that in the prformance of the work for which this prmit is issued. I shall not employ any person in any manner <br />so as to becomc subject to thc workers' compensation laws of California. and agrce that if I should bccome sub.iect to thc <br />workers' compcnsation provisions of Scction 3700 of the l-abor Codc. I shall. forthwith comply with those provisions.. <br />WARNING: Failure to secure workers' compcnsation covcragc <br />civil fines up lo onc hundrcd thousand dollars ($100.000). in <br />Scction 3076 of the l^abor Code. intcrest and attorrrcy's fecs. <br />is unlawful. and shall subject an employcr to criminal penaltics and <br />addition to thc cost of compensation. damages as provided for the <br />LICENSFN CONTR,/ACI'OR <br />DECLARAI'ION <br />I hcrchy alljrrn undcr pcnalty of pcrjury that I arn liccnsetl undcr provision of Chapler 9 lconrnrcncing with Scction 7(XX)) of l)ivision .3 <br />of thc Busirrcss and l)rot'essions Codc. and rny liccrrse is in t'ull lirrce arxl cft'cct. <br />"rqlLiccnseNurnhcr: <br />otQ I '1,x l--- <br />l):rlr.t(t/t <br />W <br />I hcrcby aflirm under Fnslty of pcrjury that theE is r @nstructk n brding sgercy for thc Frformnce of thc wort for which this Ircmil is <br />issucd (Scc. 3097, Civ. C.). <br />Lcntlcr's Namc: <br />Lcncler's Addrcss: <br />Pr, ,c. Nr.Ir"cL *o <br />I trrcby aflinn undcr pcnalty of pcrjury onc o[ thc following dcclarations: <br />Dcnrolition Pcrnrits-Ashcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) <br />-Rcquircd <br />lrltcr o[ Notitication <br />ft-t cenify rhar rhe fcdml rcgulstioos rcgffding rsbcstos Emvd m not rpplicable to thtu pmirr. <br />& "*f, ,fr., I havc rcad this applicalion .rd stste thal tlrc rborc infomulion is comt. I r8rc to @tr{rly vilh 8ll City nd County <br />Yrdhsnes snd Stste Laws rchting to building conslruction, 8rd hcrcby authoriz rcprcsnt8tires of this City 8nd County to cnl6 upon thc <br />abovc mcntioned propcrty for <br />Applicant or Agcnt <br />Pcrrnilcc nlrnc <br />*," q( 8l,r( <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />It/lisc. Equipment <br />Duct Work <br />Pre- lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rough Ductwork <br />Vents t I <br />Toilet Room I Clothes Dryer 7Dlqf W-- <br />Residential Ranqe ,l / <br />Other <br />Hood <br />Type I Hood <br />Type Il Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />!nstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release , <br />FINAL vrlBht urre- <br />Notes, Remarks, Etc.t \) <br />I <br />4 f7/)lr <br />l)ate:-7/8t 2t _ Applicant:_ <br />Conlrnclor: <br />6o^ta"\t