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M ECHAN ICAL.INSPECTOR RECORD APPROVALS DATE !D/SIG.COMMENTS OWNER BUILDER DEI,CARATION I hscby aflim undr paulty of pcrjury that I m Gxmpr from thc ConlnctoE' Licqlc lrw for thâ‚¬ followitrg rcn (Sc.70]1.5 Buines ard Profasion Codc): Any City or County which rcquirc a pcrnit to anstruct, altq, improvq &nolish or rcpair uy struauc prior to its ismcc. also rcquirc thc spplicmt for such Frmit to filc a signcd statmmt that hc or $c is licoscd pwant to thc povisios of thâ‚¬ Cont sctq's Lien*d l:w (Chapta 9. Comocitrg wilh SctioD 7000 of Division 3 of thc BsiK ed Prcfeions Codc) or that hG or shr is qmpt th@from ed thc basis for thc allcgc{ am6ion. Any violation of Scrbn 7031.5 by uy r applicutforspmitsubjetsthc spplicanttoacivilp@ltyofnotmorcth4fivchundrcddollrs($500). -1. as owner ofthe property. or my employees with wages as their sole compeosation. willdo thc work and thc structure is not intended or offered for sale (Sec.7044, Business and hofessions Code: The Conlractor's Liccnse Law does not apply to an owner of the property who builds or improves thcreon. and who does such work himself or hcrself or through his or her own employees. provided that such improvanents are not intendcd or offcrod for sale. If. however. the hrilding or improvanent is sold within one ),â‚¬o of complaion. the Orvner Builder will have thc burden of proving that hc or shc did not build or improve the propaty for the purpose of sale). -1. os owner of the property, am exclusively contracting rvith licensed contraclom to cordruct the project (Sec. 7M4. Business and hofession Code: The Contractor's License Law does not apply lo an owner of property who builds or improves thereon. and who contracts for such projects with a Contracto(s) licensed pursuant to the Contraclor's Liccnse Law). _l am exempt B. & P.C. for this DECLARA'I'ION I hereby afTinn under penalty of perjury one of the follou'ing declarations: -l have and rvill maintain a Certificate of Consent to Self-lnsure for rvorkers' contpensalion, as pro.,id"d for by Section -1700 of the tabor Code. for the pei'fonnance of the u'ork for rvhich the pennit is issued. _l have and rvill maintain workers' cornpensation insurance. as required by Section 3700 of the Labor Code. for the performance tlf the w'ork frrr u,hich this pcrmit is issued. My rvorkers' compensation insurance carier and policy number are: Policy Number: Expires: _l certi& that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so an to bccome subject to the workers'compensation laws of California. and agrec that if I should become subject to.ttfe workers' compensation provisions of Sec'tion 3700 of the Labor Code. I shall, forthwith comply with those provisions.. . WARNTNG: Failure lo sccure workers'and shall subject an employer(to criminal pcnalties and civil fines up to one hundred thousand of compensation. darnages provided for the Section and t DTCT ARATION I hereby affrrrn under penalty of pcrjury that I arn licensed under provision of Chapter 9 (cornmencing rvith Section 7000) of Division -3 of the Business and Professions Code. and my license is in full force and effect. License Nunrber: Contrgctor:_ W t hercby aflirm undr penalty of pdjury that th6e is a corotruction lmding agcncy for the pqfomcc of the work for which this pcmh b isucd (Sc. 3097. Civ. C.). Le[der's Name Lender's Address: Arr, ,cAN.r "ECrI horby affinn under penalty of perjury one of the follorving dcclarations: Dcnrolition Permits-Asbestos Notification Federal Rcgulations (Title 40. Part6) -Required Letter of Notification lfir-;ify that the lUeralregulations regarding asbcstos removalrue not applicable to this project.,( I certiff that I have read this application and state that the above inforrnation is con'ect. I agree to conrply rvith all City and County ordinances and State Larvs relating City and County to qtter upon the 7'B'Z/above mentioned property for Applicant or Agent Pennitee narne and hereby authorize of this Appliances Metal Fire Place Evaporative Cooler Furnace Compressor Misc. Equipment Duct Work Pre-lnsulation lnsulation Smoke Detectors lnstalled Rough Ductwork Vents Toilet Room / Clothes Dryer Residential Ranqe Other Hood Type I Hood Type ll Hood Grease Duct Fire Damper Openings lnstallation F.D. Drop Test Above Hard Lid Above T-Bar Rough Mech. Final Test Meter Release FINAL lo-1f,*21 TtD bt Notes, Remarks, Etc. ( _ Owner:_ Carrier: t/;