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M ECHAN ICAL.I NSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER EUILDER DELCARATION I hcdry affm unda pcnalty of pcjury that I m qmpr 8om thc CortsrcloB' Lic@ t w for thc followirg ffi (Ss.7031.5 Buin6s 8nd Prcfsion Codc): Any City or Coutrty which rcquim a pomit to @lstruct, 81t6, improvq danolish or npoir my structuc. Fior to its issmca also rcquim thc spplicet for such pamit to frle 8 sigtrâ‚¬d srarmor that hc or *c b ticascd pwant to thc provisior of tlrc Contrutor's Licmscd kw (Chrpt6 9, Comacing with Scrioo 7000 of Division 3 of thc Buins ed Prcfsions Codc) or thrt hc or shc is qmpt thacfrom ud thâ‚¬ basis for thc allcgcd qmpion. Any violation of Sctbo 7031.5 b uy applicst for a pcmit subjcts thc applicat to a civil pcodty of mt morc thm fivc hundrcd dollus ($500). _1. as owner of the property, or my cmployecs with wages as their solc compensation, will do the work and thc stnrcture b not intendod or offered for sale (Sec.7044, Business and hofcssions Code: The Contractor's License l-aw does not apply to an owncr of thc propcrty who builds or imprcves theroru urd who docs such work himsclf or hcrsclf or through his or hcr own cmployee. provided that such improvonents arc not intendod or offered for salc. If, howwcr. thc hlilding or impnovemcnt is sold within one )rcar of complaion, the Ourner Buiktcr will have the hrden of proving thd lrc or she did not build or impove the property for the prposcof sale). -1, as orvner of thc pnopcrty. am exclusively contracting with licetsed contractors to construct the projet (Sec. 7O44. Business and hofcssion Code: Thc Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracls for such projeos with a Contracto(s) licensed pursuant to thc Contractor's License law). -l am exempt under Section-, B. & P.C. for this reason. l)ittt' WORKERS' COMPENSATION DECII\RATION I hcreby affrm under peoalty of pcrjury onc ofthe following dcclarations: -l havc and will maintain a Cqtificate of Corseot to Sclf-Insure for workcrs' compâ‚¬osdion as provided for by Section 3700 of the kbor Codc for the pcrformancc of thc work for u&ich the pcrmit lg issued. -I have and will maintain workert' compquation insurance, as required by Section 3700 of the kbor Code, forthe pcrformance of the work for which this pcnnit is issuod. My workcrs' compâ‚¬osation insurancc canicr md policy numbcr are: L) tDe Z a _l certi& that in the perfonnance of the work for which this pcrmit is issued, I shall not employ any pcrson in any manner so as to become subject to the workers'compensation laws of California, and agree that if I should become subject to the workers' compensation provisioru of Section 3700 of the tabor Code, I shall, forthwith comply with those provisions.. WARNING: Failure to secure workers' compensation is unlawful, and shall subject an anployer to criminal pctr,alties and civil fines up to one hundred thousand dollars in addition to the cost of compensation, damages as provided for thc Section of the Labor Codc, interest and attorney's I hereby affrrm under penalty of perjury that I am licensed 9 (commencing with Secrion 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect.,C ,ra'q S*1Nurnber: Dete: <'(O t- Is.-rl \q <-- \ I hereby affrm under penalty of perjurythat thcre issucd (Sec. 3097, Civ. C.). agercy for the performance of the work for which this perrnit is Lender's Name: l.cadcr's Ad&ess: APPLICANT DECLARATION I hcrcby allinn under penalty of perjury one of the following declarations: Demolition Permits-Asbcstos Notification Federal Rcgulations (Title 40, Part6) -Requircd Lctter of Notification \ t certify that the ledcral regulations rcgarding asbestos removal are not applicable to this projecl. .-l ccrtiry that I have read and state that the above information is correct. I agree to comply with all City and County construction. and hereby authorize representatives of this City and County to enter upon thc above mcntiond propcty Applicant or Agort Pcrrnitec name a Appliances Metal Fire Place Evaporative Cooler Furnace Compressor Misc. Equipment Duct Work Pre-lnsulation lnsulation Smoke Detectors Installed Rough Ductwork Vents 1. t t'.lA Toilet Room / Clothes Dryer L b\^ Residential Ranqe I Other Hood Type I Hood Type ll Hood Grease Duct Fire Damper Openings lnstallation F.D. Drop Test Above Hard Lid Above T-Bar Rouqh Mech. Final Test Meter Release r -l tL f n FINAL ,\r\ ut D)u|4 o I Notes, Remarks, Etc.\ Carrier:* Policy Numbcr:. *", S(S/z-t httd6z l(