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M ECHANICAL.INSPECTOR R ECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcreby affum undcr pemlty of Frjury thal I m cxcmpt from the ContrctoE' Liccns kw for the following rcen (Scc.?431.5 <br />Busincss ond Prcfcssion Codc): Any City or County which requircs 8 pemit to construcl. aller, imprcvc, demlish oi rcpairrany <br />structw, prior to its issuance. als rcquires the spplicant for sch pcrmit to frlc a sigrcd ststcmnt thsl hc or slE is liensd pusril <br />to $c pmvisiors of the Contractor's Licusd law (Chapter 9, Comrcing wi]h Ssiion 7000 of Division 3 of lhe Busircs! rnd <br />ProfcssionsCodc)orthatheorshcisexcmptrlwfrcmsndthebasisforthcalhgcdercmplion. AnyviolslbnofSccrbnT03l.5bysny <br />spplicantforapemitsubixtsth€ spplhanttoscivilpcnsltyofrctmrcthufivchuidrcddolles($50O). <br />_1. as owncr of the propcrty. or my cmployees with wagcs ss their solc compensation. willdo the work and thc structurc is not <br />intcnded or offcrcd for sale (Scc.7044, Business and hofessions Code: Thc C-ontractor's Liccnsc l-aw does not apply to an owncr of <br />thc propcrty whcr builds or improves theroon. and who docs such work himsclf or herself or through his or hcr own employccs. <br />providcd that such impnorrcnrnts are not intcrdcd oroffcrcd for sale. If. howcrcr. the building or improverrcnt is sold within orc )lear <br />of conqlletion, thc Owner Buildcr will have thc burden of proving that lrc or she dkl not build or improve the propcrty for thc purpose of <br />sah). <br />-1. <br />as owncr of the propcrty. am cxclusivcly contracting with licenscd contructors to construct the pmject (Sec. 7(W, Business <br />arrd hofcssion Code: The Contractor's Liccnse Law does not apply to an owner of propcrty who builds or improves thcrcon, <br />and who contracts for such proicts with a Contracto(s) licenscd pursuant to thc Contractor's Liccnsc [:w). <br />_l am exetnpt under B. & P.C. for this rcason. <br />Date: Owner:_ <br />WORKF'RS' COMPFNSATION <br />NECLARATION <br />I hcrcby affirnr undcr pcnalty of prjury one of the following dcclarations: <br />_lhavcandwill nraintainaCcrtificateofConscnttoSelf-lnsureforworkcrs'compensation.as providedforbySection3Tfi)ofthc <br />Lrbor Codc, frrr thc pcrformancc of the work for which thc pcrmit is issucd. <br />_l have and will maintain workcrs' comlrcnsation insurancc. as rcquircd by Scction 3700 of thc Labor Codc, for thc pcrformancc of <br />thc work for which this permit is issucd. My workers' compcnsation insurance carricr and plicy number are: <br />l-2.IF' <br />Policy <br />i <br />_l ccrtify that in the grcrformance of thc work for which this permit is issued. I shall not cmploy any person in any manner <br />so as to becomc subjc.ct to the workcrs' compcnsation laws of California. and agroe that if I should become subict to the <br />workcrs' comlrcnsation provisions of Section 3700 of the tabor Code, I shall, forthwith comply with those provi:ions.. <br />WARNING: Failure to securc workcrs' compcnsation covcragc is unlawt'ul. and shall subjcct an cmploycr to criminal pcnalties and <br />civil fincs up to one hundrcd thousand dollars ($in to lhc damages as provided for the <br />Scclion Code. intcrcst and <br />I hcreby affirm under penalty of perjury that I am licensed undcr provision of Chapter 9 (commencing with Section 7000) of Division 3 <br />of the Busincss and Professions Code, and my license is in full force urd effcct. <br />e-Zp _3w q( <br />l-iccnse <br />I hcrcby affirm undcr penalty of fierjury that there is a construction <br />issued (Scc. 3097. Civ. C.). <br />agcncy pcrformance of the work for which this permit is <br />lrnder's Name: <br />l-cndcr's Addrcss: ' ,r, rc'NT DEC, ^ R <br />I hcrcby affrnn urrdcr pnalty of prjury onc of the following declarations: <br />Dcrnolition Pcrmits-Asbcstos Notification Federal Rcgulations (Titlc 40. Part6) <br />-Requircd <br />lrttcr of Notification <br />_l certify that the fcderal rcgulations rcgarding asbcstos rcmoval arc not applicable to this projcct. <br />and state that thc above information is corrcct. I agrcc to comply with all City and County <br />Applicant or Agcnl <br />Pcrmitcc narrc <br />rcprescqlalivcs of this City and to ugln thc <br />Appliances <br />N/etal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />Insulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranqe <br />Other <br />Hood <br />Type ! Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />Installation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rouqh Mech. <br />Final Test <br />Meter Release l/Ir <br />FINAL thl lold,t 76 <br />Notes, Remarks, Etc.I I