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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby affum under lEn.lty of Frjury thst I m cxempt from thc ConketoE' Lhcns liw for lhc following m$n (Sc.7031.5 <br />Busincss sld Prcfcssion Code): Any City or County which rcquircs r pcmit lo onstruct. rlls, imprcrc, dcmlilh or rcI[ir ey <br />slruclw. prior to its is$ree, also rEquires rhc spplicsnt for such pcmit lo filc I sigEd stalcmnt lhal h or $c is lien$d p|Nanr <br />to lhe prcvisions of fic Coilrrclor's Lbcnsd L{w (Chsptcr 9, Comrcing with Setion 7000 of Division 3 of thc Busircis ud <br />Prcfcsrions Codc) or that lE c slE is eretrpt thcrcftom and the basis for thc alhgcd exempbn. Any vblation of Sccrion 703 I .5 by my <br />spplicant for a lEmit subirts thc applicsnr ro I civil pcmlty of mt mrc thil five hundred dollsrs ($500). <br />_1, as owncr of thc propcrty, or my cmploye{s with wages as their soh compcnsation, will do thc work ard thc stnrcluc Ls not <br />intended or offered for sale (Sec.7044, Business and Profcssions Code: The Contractor's License [-aw does not apply to an owncr of <br />thc propcrty who builds or improves thermn. and who docs such work himsclf or hcrsclf or through his or her own employecs. <br />providcd that such irnprovcnrcnts arc not intcndcd or offcrcd for salc. If, however. the building or improvenrcnt is sold within onc ),ear <br />of cornphtion, thc Owncr Buildcr will have the burden of proving that he or shc did not build or improve the propcrty for thc purpose of <br />salc). <br />_1. as owncr of thc property, am exclusivcly contracting with liccnscd conlractors to construct thc projcct (Scc. 7W, Busincss <br />and Profr:ssion Code: The Contractor's Licensc Law docs not apply to an owncr of property who builds or improves lhcreon. <br />and who cotrtracts for such projccts with a Contraclor(s) liccnscd pursuant to thc Contraclor's License Law). <br />-IamcxcmptundcrScction-.B.&P.C.forthisrcason' <br />WORKF' RS' COM PT'NSATION <br />DF'CI AR.ATION <br />I hcrcby affirm undcr pcnalty of pcrjury onc of the following dcclarations: <br />-lhawudwillmintsiDaCcnifEatcofcoreDttoSclf-lnsuEforvorlm'@rpcnsatbn,s <br />provlledforbysetion3T00ofahe <br />trtsr Codc. for thc psforc of rhc wh fu which thc pqmit is issucd. <br />-fl mrc ana witl mhtsin workfl'@mpcffation imnre, s rcquired by Setion 3?OO of the kbor Codc, for rhc pcrfor:mc of <br />thc wqk for which this permir ir is$Ed. My worlffi' smpcBation insurc mbr ard policy numbcr rc: <br />( <br />Policy , <br />_l ccrtili that in the performancc of thc work for which this permit is issued, I shall not employ any person in any manner <br />so as to bcconrc subject to thc workers' compensation laws of California. and agrcc that if I should bc.conrc subjcct to thc <br />workcrs' comlrcnsation provisions of Section 3700 of the labor Codc, I shall, forthwith comply with thosc provisions.. <br />WARNING: Failurc lo sccure workers' comgrcnsation coveragte is unlawful. and shall subjc.ct an employcr to criminal pcnaltics and <br />civil fincs up lo onc hundrcd thousand dollars (S100.00O), in addition lo the cost of compensation. damages as provided for thc <br />Scction 3076 of thc labor Code, interest and attorncy's fccs. <br />I <br />I ICI.'NSFN CONTRACTOR <br />DECLARATI(TN I <br />I hcrcby alfirnr undcr pcnalty of pcrjury that I am liccnscd undcr provision of Chapter 9 (comnrcncing with Scction 7Un) ol Division 3 <br />of lhc Busincss and Profcssions Codc. and nry liccnsc is in full forcc and cffect. <br />a <br />Liccnsc )Nurnbcr: <br />W <br />t h.rcby s,rrm urdcr Ff,sty of Frjury thal tlre ir a on*ruabn bndiry rgcrcy for ih. pdfm of dE wL br wibh this psmi b <br />ilsuc{ (Se. 3097, Civ. C.). <br />[.rdcr'3 N!m; <br />Lrndcr's Address: <br />APpI tCANr DFCLARAIION <br />I herebyaftmunder penalty of perjury one of the following dcclarations: <br />Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) <br />-Rcquired <br />Letter of Notification <br />_l enify thst th€ federsl rcgulatioru rcgading &ibestos rcmv8l m not rpplicabh to this prcj.Tt. <br />lA/tsrify rfrrr f furc rcrd rhir 8pplicstion ard st8tc thst thc rborc infornutioo is corcct. I rgrc to @mply with rll City md Counay <br />' oiimnccs and State Lrws rchring to building @nstructioo, 8rd hercby 8uthoriz rcprcsntariB of this City srd County to cnls rpon tlE <br />above mcntioncd property for <br />Applicant or Agcnt <br />Pcrnritcc nanrc <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />[t/isc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Drver <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type ll 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 rl <br />FINAL 9/t,a /2, <br />Notes, Remarks, Etc.(/I l-/ <br />---j) <br />l)ate:_ Owner:_ <br />ts <br />Canier: EZ Y S "{J I ( rxpires:lP> <br />I)nte:O)/Jl conrracroX 'A{- <br />I w^(*>{ffZ *, orl 03[Jl <br />rh|L\f L;n4Z <br />I <br />rfirda <br />I