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M ECHANICAL-I NSPECTOR R ECOR D APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby arlirm undcr pcnElty of perjury that I m excmpt frcm thc ContretoN' Licn$ trw for thc followirg.rcarcn (58.7031., Busincss ard Profcssion Codc): Any City or County which requircs a pcmit to @ns|ruct, altr, impove, demlish or rcp8lr my suucnrc. Fior to its issm. slso rcquircs the applbsnt for swh pcmit to tilc I sigrcd stslcrenl thal hc or CE is lieosd pwul to tlE prcvisions of the Conuetor's Llrnsd trw (C-hapter 9. Cotmrcing with SGibn 7000 of Divisbn 3 of thc Eusircss md Prcfcssions Codc) or that he or shc is cxempt lhcrcftom ard thc btris for the allcgpd cxcmption. Any viololion of S6tbn 703 I .5 by any spplicanr for a lErmit $ubjects thc applicant to a civil pcmhy of not mrc the livc hundrcd dollm ($500). -1. as owner of thc propcrty, or my employees with wagcs as thcir sole compcnsalion. will do tlre work and the stnrture is not interdcd or offercd for sale (Sec.7044, Business and Professions Code: Thc Contractor's Liccnsc [:w does not apply to an owner of thc property who builds or improves thercon. and who does such work himsclf or hersclf or through his or her own employecs, provided that such improvenrnts arc not intendcd or offcred for sah. If. howevcr. thc building or improverrcnt Ls sold within one )â‚¬ar of conphtion. the Owner Buildcr will have thc burden of proving thal trc or she did not build or inprove thc proprty for ttre puryrcsc of sale). -1, as owner of the propcrty, am exclusivcly contracting with licenscd contraclors to construct thc proict (Scc. 7044, Busincss and Profession Code: Thc Contractor's Liccnsc Law docs not apply to an owner of property who builds or improves thcreon, and who conlracts for such projects with a Contracto(s) licenscd pursuant to thc Contractor's Licensc l-aw). I am excmnt B. & P.C. for L Z / I hcrcby affirrrr under penalty of prjury one of thc following dcclarations: I have and will maintain a Ccrtificate of Consent to Self-lnsure for workcrs' compcnsation, as providcd for by Sc.ction 3700 of thc I-abor Code, for thc perfornrancc of the work for which the permit ls issued. -l havc and will maintain workcrs' compensation insurancc, Bs rcquircd by Section 3700 of thc [:bor Codc, for thc lrcrfornuncc of thc work for which this pcrmit is issucd. My workcrs' compcnsation insurance carrier and p,olicy number arc: Crrrier: Policy Number: Expires: _l ccrtify that in the performance of thc work for which this pcrmit is issucd, I shall not cmploy any pcrson in any manpr so as to bcconre subjcct to thc workcrs' comgrcnsation laws of California. and agrce lhat if I should becomc subject to thc workcrs' compcnsstion provisions of Section 3700 of the Labor Codc. I shall. forthwith comply with those provisions.. WARNING: Failurc to securc workcrs' corrrpcnsation coverage is unlawful. and shall subjcct an cmploycr to criminul pcnaltics and civil fincs up lo onc hundrcd thousand dollars ($100,000). in addition to damages as providcd for the Scclion 3076 of thc Code.and atlorncy's fecs.J G Z I hcrcby affrm under penalty of pcrjury that I am liccnsed under provision of Chaptcr 9 (comnrncing with Scction 7000) of Division 3 of thc Business and Professions Code, and my license is in full forcc and effcct. Licensc Dale: Nuntr,'ur: W t hâ‚¬rcby affrm undcr Fmlty of Frjury that tlm is I oostructbn hDditrg 8gcrcy for thc Frfoffi of thc wk for which this pcmil k issued (Se. 3097, Civ. C.). l-cnclcr's Narnc: [.cnder's Addrcss: APPLICANT NECLAITATION I hcrctry affrnn undcr pcnalty of pcrjury onc of the following declarations: Dcmolition Pcrnrits-Asbcstos Notification Fcderal Rcgulations (Title 40, Part6) -Requircd lrttcr of Notification \_l ccrtify that thc federalrcgulations rcgarding asbcstos rcmovalare not applicable to this project. _l ccrtify that I havc rcad this application and statc that thc abovc information is correcl. I agrcnc to comply with all City and County ordinances and Statc Laws rclating to building construction.the abovc mentioned property for Applicunt or Agcnt Pcrnrilcc namc rcpresentatives of this City and lo cnlcr Z/ Appliances lVletal Fire Place Evaporative Cooler Furnace Compressor tMisc. Equipment Duct Work Pre- Insu lation Insulation Smoke Detectors lnstalled Rouqh Ductwork Vents Toilet Room / Clothes Dryer Residential Ranqe Other Hood Type I Hood Type ll Hood Grease Duct Fire Damper Openinqs !nstallation F.D. Drop Test Above Hard Lid Above T-Bar , ra I I tl t .a Rouqh Mech.Drttffn 7t il\ Final Test | 'l Meter Release l\ FINAL loll)na A/Nh Notes, Remarks, Etc.I I \I\) Sa /veP r?L -l I I