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M ECHANICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hereby affum unds penrlty of perjury that I m cxcmpt from the Contrrcto6' Licenw Law for thc following @sn (Ss.7031,5 <br />Busincss ard Pmfcssion Codc): Any City or County vhich rcquircs s pemit to @nsirci, dls. imprcrc. dcrmlish or rcpoir any <br />struchre, prior to its isswre, slso requircs thc applksnl for such Fmit to fih 8 sigred stslcmnt thar hc or shc h liensd puNanr <br />to the pmvisioni of tlE Contmtff's Liccnrcd lrw (Chapter 9. Comrcrcing with Section 7m0 of Divisbn 3 of the Busincss and <br />PrcfessionsCode)orthsthcor$heiscxcmptthcrcftomlndtlEbosisforthesllegedexemption. AryviolsthnofscctionT03l.5byrny <br />rpplicont for I pcmit sublrcls thc spplicsrl lo a civil pemlty of mt mrc than five hundrcd doll(s (5500). <br />-1. <br />as owner of the proFrerty. or my employces with wagcs as thcir solc compensation, will do the work ud thc stnrcturc is not <br />intcndcd or offered for sale (Sec.7044, Business and Professions Code: The Contractor's Liccnse l.aw does not apply to an owner of <br />the progrerty who builds or improvcs thercon. and who does such work himself or hcrsclf or through his or her own employccs. <br />providcd that such improvenrcnts are not intcnded oroffcred for sah. If. however. thc buiHing or hpmvenrcnt is soH within orc ),ear <br />of complction, the Owncr Builder will have the btrden of proving thal he or shc ditl not build or improvc the propcrty for the pur;nse of <br />sah). <br />-1. <br />as owner of the property. am exclusively contracting with liccnscd contractors lo construct thc projccl (Sec. 7W. Busincss <br />and Profcssbn Code: Thc Contractor's License Law does not apply lo an owncr of property who builds or improves thcrcon, <br />and who conlracls for such prnjects with a Contractor(s) licenscd pursuant to the Contraclor's License [aw). <br />-lamcxemptundcrScction-.B.&P.C.forthisreason.I1., r -.Jlo,na-' <br />t <br />I hcrchy affrm undcr penalty of pcrjury one of lhc following dcclarations: <br />_lhavcandwill rnaintainaCcrtiticatcofConscnttoSclf-lnsurctbrworkcrs'cornpensation.us providedforhySeclion.lTfi)ofthc <br />Latxlr C-'rdc. for thc pcrformancc of thc work t'or which thc pcrmit is issucd. <br />-l <br />havc and will rnaintain workers' conrlrcnsalion insurancc. as rcquircd hy Sect ion 37fi) of lhc [:bor Codc. for thc pcrformancc of <br />thc work for which this prnrit is issucd. My workcrs' conrJrcnsation insurancc carricr and prlicy numbcr arc: <br />Carricr: <br />Policy <br />_l ccrtify that in thc pcrformance of the work for which this permit is issucd. I shall not cmploy any pcrson in any m&nncr <br />so as to bccome subjcct to the workcrs' comyrcnsation laws of California. and agrec thal if I should bccornc subpct to the <br />workcrs' compensation provisions of Section 3700 of thc Labor Codc. I shall. forthwith comply with thosc pmvisions.. <br />WARNING: Failure to sccurc workers' comgrcnsation covcrage is unlawful. and shall subict an cmployer to criminal pcnaltics and <br />civil fines up to one hundred thousand dollars (Sl0O,(n0). in addition to the cost of compcnsation. damages as provided for thc <br />Scction 3076 of the l-abor Codc. interest and atlorney's fecs. <br />LICENSED CONTRACTOR <br />DECLARATION <br />I hcrchy alfirm undcr pcnalty of pcrjury that I am licenscd undcr provision of Chaptcr 9 (corrrrncncirrg with Scction 7ffru) of Division 3 <br />of thc Business and Profcssions Code. and nty licensc is in t'ull lbrcc and cllcct. <br />Liccrrsc Numbcr: <br />W <br />I hcrcby 8fftrm urdcr pendty of pcrjwy that thm is 8 onstructbn hnding 8gercy for th€ prfom of thc mrk fo! whhh ahis pcrmil is <br />issucd (56. 3097, Civ. C.). <br />Lcnder's Name: <br />lrndcr's Address: <br />APPI ICANT DECLARATI()N <br />I hrcby allirm undcr Jrcnalty ol'pcrjury onc of lhc follorving dcclarat ions: <br />Dcrnolition Pcrrnits-Asbcstos Notificaliorr Fcdcral Rcgulations ('l'itlc 40. Parl6) <br />-Rcquircd <br />Lcttcr of Notificalion <br />-l <br />ccnify lhal lhc fcdcral rcguhlions rcguding asbcskrs rcmvul arc not dpplicilhlc Io lhis p(rjcct. <br />_l ccflity thnl I havc rcd this application and slalc that thc trtnvc inlonMtion is co[ccl. I agrc lo comply wilh all Cily and Counly <br />ordinonccs Bnd Shlc Laws rclating to building constructtrn. dxl hcrcby aulhorize rcprcsltalivcs ofthis City and Counly to cnlcr uFrn thc <br />abovc mntioncd prrlxny for inspcction pury[scs. <br />Applicant or Agcnt I )ill(' <br />Appliances <br />lVleta! Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsu Iation <br />Smoke Detectors Installed <br />Rouqh Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rouqh Mech. <br />Final Test <br />Meter Release /l -\ <br />FINAL 7 lt ql zt th)12"/ <br />Notes, Remarks, Etc./t <br />Date:-Applicant: <br />(lontracftrr: