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M ECHANICAL.INSPECTOR REGORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hreby affm unda psEtty of pgjury thst I m q6pt fiom thc CoilractoB' Licre Lrw for thc following ren (Sc.7031.5 <br />Buincs and Prof*ion Codc): Ary City or Cou[ty which rcquiE a pqmt to onstruct. altc, imprcve danolish or rcpair uy <br />struc1u& ttrbr to its issumcc, also rcquirc thc eplicmt for such pqrnit to filc I signcd statmt that hc or strc b licos€d pwaot <br />to thc provisioB of thc Contrrctor's Liccnscd trw (Chapq 9. Comcrcitrg with Sctiotr 7000 of Division 3 of thc Buirs ed <br />Profsiou Codc) or thEt hc or shc is cxmpt tlEefrom md thc basis for thc sllcgcd cxmption. Ary violaion of Sctbn 703 1.5 by ey <br />applicant for a pcnnit subjcts thc applicmt to a civil pculty ofmt morc thm fivc hundrcd dollm (t500). <br />-I, <br />as owner ofthe propcrty, or my cmplollee with wages as thcir sole compcnsation, will do thc work and thc stnrcture is not <br />intendod or off€rcd for salc (Sec.7044, Business and hofessions Code: The Contractor's Lic€nse Law docs not apply to an owner of <br />thc property who h,rilds or improvc theroon, and who does such wort himself or herself or through his or her own employce, <br />provided that such improvcnrents arc not intcnded or offcrcd for sale. If,, howevcr, thc building or improvanrent is soH within onc )car <br />of conplaiorL the Ovmer Buildcr will have the hrden of proving thd tre or slrc did not buiH or iryrove the propcty for the purposc of <br />sale). <br />-1, <br />8s owncr of the prop€rty, am exclusively contracting with liccrsed contracton to construct the projcct (Sec. 7044, Buiness <br />and hof€ssbn Code: The Contractor's License Law does not apply to an owncr of propcrty who builds or improves thereon. <br />and who contracts for such projects with a Contraclo(s) licerued pursuant to the Contractor's Liccflse Law). <br />-l <br />arn exempt under Section-, B. & P.C. for this rcason. <br />flolo. <br />YOBTEBS-qOMPINSAIIAN <br />DECI.AEAITAN <br />I hreby allim undo pcnalty ofpajury onc ofthc following delantiom: <br />,z-l have ud will maintain a Cstificatc of Commt to Self-lnsrc for workm' composatioo u prcvidcd for by Sstion 3700 of the <br />/ Labor Code. for thc psfomuce of thc rcrt for which lhc pqmit is isucd. <br />Dk. <br />(th'c *uort <br />and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code, for the performance of <br />for which this permit is issuod. My workers' compensation insurance carrier and policy numkr are: <br />co. oF -OF t UADTA <br />oo G f 2 2- <br />_l certi& that in the performance of thc work for which this permit is issued, I shall not employ any person in any manner <br />so as to become subject to the workers' compensation laws of Californr4 and agree that if I stpuld become subject to the <br />workers' compensation provisions of Scction 3700 of the tabor Code I shall, forthwith comply with thosc provisions.. <br />J <br />WARNING: Failure to s€cure workers' compensdion coverage is unlawful. and shall subject an anployer to criminal penalties and <br />hundred thousand dollars ($100,000). in addition to the cost of compensation, damages as provided for thecivil fines to one <br />Scction Codq intcrest and attorn€y's fees. <br />a,D Ad?) P.4ecosA <br />LICENSEN CONTRACTOR <br />DECIAIIATION <br />I hcneby affirm under penaltyof ffiury that t am liccnsod undcr provision of Chaptcr 9 (cornmencing with Section 7000) of Division 3 <br />of the Bwiness and Profcssions Code, and my licensc is in full forcc md efhcr. <br />Cto c qqL{.;eg <br />Number:3 <br />W <br />t hotbyaffim ud6 paultyofpa;jurytha tlscba@nnrudion lodingagcy forthcpcfomc ofthcwoil 6rwhichthbpqnn b <br />isucd (Sc. 3097. Civ. C.). <br />l.t'rrtlcr's Narttc. <br />Lender's Address: <br />APPLICANT DEC I.A,RATION <br />I hur*y aftm under pcnalty of pcrjury one of the following dcclarations: <br />Demolition Pcrmits-Asbestos Notification Fodcral Rqgulations (Title 40. Part6) <br />-Required <br />Lettcr of Notification <br />_l certi& that the lederal regulations regarding asbestos removal ,!re not applicable to this projed. <br />is correct. I agree to comply with all City and County <br />above mentioned property for <br />)f,pplicant or Agant <br />\*r,n*n.me <br />representatives <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-!nsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork <br />Vents <br />Toilet Room / Clothes Dryer 1 <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct \ <br />Fire Damper / <br />Openinqs <br />Installation <br />F.D. Drop Test <br />Above Hard Lid //ll /I <br />-a <br />Above T-Bar 7/t0/ /trDl@A vDt, <br />Rough Mech. <br />Final Test <br />Meter Release //It , <br />FINAL /UD/2r @thr.6dd <br />Notes, Remarks, Etc <br />\ <br />./ <br />ZT