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M ECHAN ICAL.! NSPECTOR RECORD APPROVALS DATE !D/SIG COMMENTS OWNER BUTLDER DEIrcARATION I hdcby affirm undff poalty of psjury thar I m qempt fiom thc Conhmtos' Licre tJw for thc followirg twn (Sa.7031.5 Buines atd Profesion Codc): Aoy City or Coudy which rcquis a pornit to coNtruct. alta, improvc danolish or Epair my suuc{ure. prbr to its issuacc, also rcquire thc applicut for such pcmit to lilc I signed statmmt thd he or drc is licascd pEmt to thâ‚¬ prcvisioN of thc Contrrctor's Lieucd Law (Chapt6 9. Commcing with Scrion 7000 of Divisioo 3 olthc Buirc md Profsiom Codc) or that hc or shc is qcmpt th@from and thc bssis for thc allcgcd qmption. Any viohtion of Setbn 7031.5 by uy applicmt for a pcrnit subjets thc applicut to a civil pcrulty of not morc th6 fivc hundrcd dolla ($500). -1, as owner of the p,roperty. or my employees with wages as their sole compersation. will do the work and the stnrclure is not intendod or offered for sale (Soc.7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of the property who builds or funproves theron, and who does such work himself or herself or through his or her own cmployees. provided that such improvanents are not intâ‚¬ndod oroflbred for sale. l[, howwcr, the building or improvernent is sold within one ]â‚¬ar of cornplaion, the Orner Builder will have the hrden of proving tha he or she did not build or improve the propoty for the purposcof -&\ffiTsllf,ffi rEJ;H'.rilH"ffJffi T$l;ffi ;:ffi :l",trffi,iff ffi,'r"fff ;]"H,H:T who contracls for such projecrs with a Contractor(s) licensed pursuant to thc Contractor's License l-aw). am exempt B. & P.C.reason. I hereby afftnn unds penalty of pojury one of the following _l have ard will maintain a Certificate of Consent to Self-Insure for workers'compqrationr as pr,ovidcd for by Section 3700 of the I-abor Codc for the pcrformance of the work for which the perrnit b issued -l have and will maintain worketrs' compensation insurance, as required by Setion 3700 ofthe Labor Codc, for thc pcrformancc of the work for wNch this permit is issuâ‚¬d My workers' compersation insurancc carrier and policy numbcr are: \ WARNTNG: Failure to sccure workers' compensation coverage is unlawful. and shall subject an enrployer to criminal pcnalties and civil fines up to one hundred thousand dollars ($100,000). in addition to the cost of compcm{ltion, damages as provided for the Section 3076 interest and attorney's foes. LrqENsEp CoNTRACTOR DECTI\RATION I hereby affirm under pcnaltyof ffiury tha I am licâ‚¬osod under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, ard my licensc is in full forcc and effect. Licensc Class: Licease Number: Date: W I hodry affirm undq p68lty of pqjury thd thft b a @ngilclion ladiry ag@y for thc pafomcc of thc mrk br which this Fnit b icaucd (Se. 3097, Civ. C.). Lcndcr's Name: Lender's Address: A,,LICANT DE.LARATION I hâ‚¬ldryaffirm under pcnalty of perjury one of the following declarations: Demolition Permils-Asbestos Notification Federal Regulations (Title 40, Part6) -Required letter of Notification with all City and County above mentioned property for County to entcr upon the 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 Range 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 JI FINAL /0-fY?Z(/cctt /uFb 5 -Xtl Notes, Remarks, Etc. \ that in the performancc of the work for which this perrnit is issued. I shall not employ any pcrson in any manner so ,ls to become subject to the workâ‚¬rs' compensation laws of Californiq and agree that if I should become subject to thc workcrs' compensation provisions of Section 3700 of the Labor Code, I shall. forthrvilh comply with those provisioru.. Contractor: q &hr