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M ECHANICAL-INSPECTOR RECORD a <br />APPROVALS DATE ID/SIG.COMMENTS oWNERBUTLDERDEL(XRATTON . . ia <br />I hercby affrm undo peoalty of perjury thsl I m crcmpt fom the Conlrcto6' Lkcns lrw for thc following Mrcn (Src.7)..j1.5 <br />Busincss ard Pmfcssion Code): Any City or Couny which rcquircs a [mit to @nslnrct. alaei improre. &mlish or rcpoir ar.y <br />slruclum. prk r lo its issurrce, 8ls rcquircs thc qpplhet for such Fmil to filc 8 sigrcd statemnt lhsr hc or shc is liensd puruut <br />to the pmvisions of thc Contrctor's Liccnsd tiw (Chspter 9. Comcrcing wilh Section 7000 of Division 3 of thc Busincss and <br />Prcfessions Codc) or that hc or shc is cxcmpl thcrcfrcm and thc basis for ihc slleg€d cxctrlption. Any violation ofscrion 703 1.5 by any <br />applicsnt for 8 pcmit subjccts thc spplisant lo I civil penrlty of not mrc than fivc hundrcd dolltrs (5500). <br />_1. as owner of the property, or my cmployees wilh wages as their solc compensation. will do thc work and the structurc [s rmt <br />intendcd or offered for sale (Scrc.7044. Business and hofessions Code: The Contractor's License l-aw does not apply to an owner of <br />thc propcrty who btrilds or funprovcs lhc{con. ard who docs srch work himsclf or herself or through his or hcr own employees. <br />providcd that such improvenrnls are not inlcrded or offered for sah. lf. howevcr. ttrc building or in{norrenEnl is sold wilhin one }tar <br />of complcthn. thc Owner Builder will havc thc burden of proving that tE or shc dkl not build or inqrrove ttrc fnop"rty for thc purpsc of <br />sale). <br />_1. as owncr ol'thc propcrty. anr cxclusivcly conlracting with liccnsctl c()nlraclors lo construct thc projccl (Scc. 7(M, Busincss <br />and l\uli:sskln(}ldc: ThcContractt)r'sl.iccnseLawdocsnotapplyloanowncrol'propcrtywhohuildsorirnprovcsthcrcon. <br />and who conlrncts lilr such projccls with a (lontractor(s) licenscd pursuunl lo thc Contraclor's Liccnsc l-aw). <br />-latttcxctIlplultdc.rScction-.B.&P.C.filrlhisrcastrn, <br />( )rr ncr: <br />WORKERS' COMPFNSATION <br />DECLARATTON <br />I hcrcby alfirm undcr penalty of pcrjury one of thc following dcclarations: <br />-l <br />havc and will maintain a Certificate of Consent to Self-lnsure for workcrs' compensation. as provided for by Section 3700 of the <br />I-abor Codc, for the performance of thc work for which the permit ls issucd. <br />-l <br />havc and will maintain workers' compcnsalion insurance. as rcquircd by Scction 37fi) of thc l,rrbor Code. for thc grcrformnncc of <br />thc work for which this prmit is issucd. My workcrs' comlrcnsation insurancc carrier and plicy numbcr arc: <br />Carrier: <br />Policv Number: Exoires: <br />JI <br />-l <br />ccrtify that in thc performance of thc work for which this pcrrnit is issucd. I shall not cmploy any pcrson in any numner <br />so as to bccomc subjcct to the workcrs'conrpcnsation laws of California. and agrce that if I should bccomc subjcct to the <br />workcrs' compcnsation provisions of Scction 3700 of the Labor Code. I shall. forthwith comply with thosc provisions.. <br />WARNING: Failure to sc-cure workcrs' compensation coverage is unlawful. and shall subict an enployer to criminal pcnalties and <br />civil fincs up to one hundred thousand dollars ($100.000), in addition to thc cost of compensation. damages as provided for thc <br />Sc'ction 3076 of thc labor Codc. inlercst and attorney's fees. <br />Date: <br />LICENSED CONTRACTOR <br />DECLARA'I'ION <br />I hcrcby af'lirrn urrdcr penaltyof pcrjury that I arn liccnscd undcr provisiorr ol'Chuptcr 9 (commcncing with Scction 7Un) of Division 3 <br />ol' thc Ilusirrcss and Profcssiorrs Codc. antl nry licensc is in full [<rrcc imd cl'll'ct. <br />Liccnsc Class: Liccnsc Number: <br />Dsle: Conlraclor: <br />W <br />I hcrcby alljrm undcr Fnalty of pcrjury lhdl lhcrc is a conslruction lcnding ugcrey for Ihc pcrlbrntarcc ofthc wrrk for which lhis ttrtrril is <br />issucd (Scc. 3097. Civ. C.). <br />kndcr's Namc: <br />Lrndcr's Addrcss: <br />APPLICANT DFCLARATION <br />I hcrcby atfinrr undcr pcnalty of pcrjury onc of thc following dcclarations: <br />Dernolition Pcrrnils-Asbcstos Notification Fcdcral Regulations (Title 40. Part6) <br />_Rcquirccl ktlcr of Notification <br />-l <br />enify thrt the fcdsal rcgulalions rcgsding sbestos rcmBlrc not appttsble to thir pmjet. <br />-l <br />cgtify thar I hsw rcad this applbstion atd srde lhrt 0r sbow infomtion ir cmt. I 8gE to @mply wilh sll Cily snd County <br />ordiores aod State [iws clstitrg to building on*nrcrbn ard hoeby sulhoriz rcprcsilrtiB of lhh Ci]y ard Couty to eots upon thc <br />abow miliored prcperly for insFction purlDss. <br />Applicant or Agcnt <br />Pcrnrilcc rttruc <br />l\otn. <br />Appliances <br />lVletal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />[tIisc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork <br />Vents <br />Toilet Room I Clothes Dryer <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type !l 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 />Rough Mech.cltlltd ,r,t2) <br />Fina! Test ttl I (-.- <br />Meter Release ,--r\ <br />FINAL <br />NoteslRemarks, Etc.q -? i-?b fu-T?'6 il <br />\-.7 <br />L <br />- <br />-----r----- <br />Dale: <br />Applicrant: