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M ECHANICAL.I NSPECTOR R ECOR D <br />APPROVALS DATE ID/SIG COMMENTS OWNEN, BUTLDER DELCARATION <br />I hcrcby affum under Jrcnrlty of Jrcrjury thst I m cxempt ftom lhc G,ntrrctoB' Licenrc hw for th€ following rc&sn (Stc.7031.5 <br />Busincss cnd Profcssion Code): Any City or County which rcquircs r pemil to @nsNruct, alts, inprcrc. dcmlish or rcSir aEy <br />structre. trhr to its issure. 8ls rcquircs thc spplbmt for swh pcmit to filc I sigrcd st&lemnt thst ]E or shc b licmsd puMt <br />lo thc pmvisbns of tlE Contrclor's Liccosd llw (Chspto 9. Comrcrcing wilh Scction 7000 of Division 3 of thc Business 8nd <br />Pmfcssions Codc) or thst hc or she is exempt thercftom snd thc besis for thc alleged cxemption. Any viohtion ofscrbn 703 1,5 by sny <br />applicant for 8 lEmit subjsls thc applicant to 8 civil pcnllty of not mrc the five hundrcd dolles ($500). <br />I <br />t{ <br />-1. <br />as owncr of the propcrly. or my cmployces with wagcs as their soh compensation. will do thc work and the struture is rrcl <br />intcndcd or offcred for sale (Sec.70l4. Business and Pmfcssions Codc: The Contraclor's License hw does not apply to an owner of <br />thc prnperty who builds or impmves thercron. and who does such work himself or hcrsclf or through his or her own employees. <br />provided that such improvenrcnls are not interdcd or offcrcd for sale. lf. however. thc building or inprovenrnt is sold within onc )rar <br />of completion. thc Owner Buildc'r will have thc burden of proving thal hc or she dkl rnt build or improve the propcrty for thc purynsc of <br />sah). <br />-1. <br />as owner of the proprty. am exclusivcly contracting wilh liccnscd contractors lo construct the projcct (Sec. lOM. Busincss <br />and Professirn Codc: The Contractor's Liccnsc law does not apply to an owncr of proJrcrty who builds or improves thereon. <br />and who contracls for such projects with a Contracto(s) licenscd pursuant to thc Contractor's License kw). <br />-I <br />B.lirr this rcason. <br />I hcrchy atllrnr undcr penalty of pcrjury onc of thc tblkrwing <br />-l <br />have ard will maintain a Certifrcate of Consent to Self-lnsure for workcrs'compensation, as providcd for by Section 37fi) of the <br />I-abor Code, for thc pcrformarrcc of the work for which thc pcrmit ls issued. <br />-l <br />have and will maintain workers' compcnsation insurancc. as requircd by Section 3700 of thc Labor Code, for the performancc of <br />the work for which this permit is issued. My workers' compcnsation insurance caricr and policy numhr are: <br />Policv Number: Exoires:JU <br />-l <br />certify thal in the perfornrance of thc work for whhh this permit is issued. I shall not employ any pcrson in any manner <br />so as lo bccomc subjcct to the workers' compcnsation laws of California. and agree that if I shnuld become subpct to the <br />workcrs' compcnsation provisions of Section 3700 of thc lahor Code. I shall. forthwith comply with thosc provisions.. <br />WARNING: Failurc lo sccure workers' comyrcnsation and shall subjcct an cmployer to criminal pcnaltlx and <br />civil fines up to onc hundrcd thousand dollars ($l lo thc cosl of compcnsation. damagcs as providcd for thc <br />Scction 3076 of and <br />DECLARATION <br />I hereby affirm under penalty of perjury that I am licenscd undcr provision of Chapter 9 <br />of the Busincss and Profcssions Codc. and my licensc is in full forcc and cffc"ct. <br />7000) of Division 3 <br />License Class: Licensc Number: <br />l)ate: <br />W <br />I hcrcby arftrm under Fmlty of perjury thd tlm is 8 onstruction brdinS rycrcy for thc pqfmre of the wtrl for which this pcrnit b <br />issucd (SE. 3097, Civ. C.). <br />lcnder's Name: <br />lrnder's Addrcss: <br />Aro, ,c NT D"c, ARAT, <br />I lrrcby affmn undcr pcnnlty of pcrjury onc of thc following dcclarations: <br />Dcmolition Pcrmits-Asbcstos Notificalion Fcderal Regulations (Titlc 40. Part6) <br />-Required <br />lrttcr of Nolificalion <br />-l <br />ccrtify that the federalregulations regarding asbestos rcmoval ffe nol applicablc to this projcct. <br />-l <br />certify that I have read and state thal thc abovc inforrnation is correct. I agrcc to comply with all City and County <br />ordinanccs and Statc L:ws <br />atxlvc rncntioncd property for <br />Applicant or Agcnt <br />Pcrrnitcc namc <br />and hcrcby authorize reprcscntatives of this City and <br />-\ <br />ufnn thc <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />It/isc. Equipment <br />Duct Work <br />Pre-lnsulation <br />Insulation <br />Smoke Detectors Installed <br />Rouqh Ductwork <br />Vents <br />Toilet Room I Clothes Drver <br />Residential Ranoe <br />Other <br />Hood <br />Type I Hood <br />Type Mood <br />Grease Duct <br />Fire Damper <br />Openinqs <br />Installation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rouqh Mech. <br />Final Test <br />Meter Release t/\ <br />FINAL lA-b"'2 urfl.ru <br />Notes, Remarks, Etc.\\I <br />\-/ <br />I <br />/G <br />Dulc: