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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hocby aflirm unda peralty of pcrjury that I iln excmpt film the CodracloN' LiccN law for the following rcen (Se.7031.5 <br />Businss ud hofcsion Code): Any City or County which rcquira a pcrmit to construcl. alt6. improvq dmolish or rcpair any <br />structue. prior to ils isumcc. also rcquira the qplicant for such pcmil to file a signed statmmt that hc or shc b licsed pmumt <br />to the prcvisions of thc Contractor's Licensed Law (Chapto 9. Commencing wilh Setion 7000 of Division 3 of the Busincs and <br />PrcfcssionsCodc)orthathcorsheisexemptthdefromandthcb6isfortheallegedcrmption. AnyviolationofScctionT03l.5byany <br />applicantforapcrmitsubjectsthc applicantloacivilpflaltyofnotmorethanfivehundreddollars($500). <br />l.as otrflcrofthcprolErly.ormyemployeeswilhwasesaslhcilsolecotnpensation.uilldotheworkmdlheslruclueisnot <br />inlsrricrl orolTcredforsle(Sa.T044.BusincsandProfcssionsCodc:'l'hc(-ontraclor'sl.icenseLa\vdo6notapplytoanownerof <br />lheprcluly rvhohrilGorimgmrvethflq)n.ildwhodoqssuch\rrrkiimselforherselforthroughhisorherorvncnrploycs. <br />providedthalsuch irnJnovorentsuenolintodedoroffqedforrle.lf.hots'o.thebuildingorimprovenlmtiss)ldsilhinoncyd <br />ofconrpldion. the o$'ntr Buildq will ha\€ the txrrdm ofproving that hc or she did not huild or improve the prcFEty for thc puqFs of <br />sle). <br />l. s o\r ner ofthe prop€Tty. m exclusively contractin8 \r-ith licenssl conlracloE to construct lhe projst (Ss. 7014. B6inN <br />and l,mfqsionCode:TheContractor'sLicenseLawdo6ndapplvtoanorvnoofpropenyrvhobuildsorinrprovesthqmn. <br />and \\'ho conlmcts for such projets rvilh a ('onlraclo(s) licflscd pursuanl to lhe Contraclor's Licosc l-aN). <br />I atr eretnpl under Srlion- . B. & P-('. ftrr lhis reoon. <br />I)rlc <br />I hcrcby allirnr <br />0[ ncr: <br />\YORKURS' ('OIIPENSA iioN <br />Dtt( l,ARA',ilON <br />onc olthc folkxviug rlcclar ati(rns:undcr penalty ofpojury <br />l harc ancl \ ill nraintain a Cedificate ofConscnt lo Sclf-lnsurc lor $orkcTs compensation. as provirled fol by seclion lT00 oflhe <br />l.alx)r (i)dc. for the pofonnance ofthe $ork for which lhc po]nil is issucd. <br />lhc work for thh pflnit is ised. My rvorkm compdsation iNurance cmio md policy numba ue: <br />('arlicr: <br />Policy u Erpir6:a4 <br />_l ccf,ify that in thc pcrformuce of thc work for which this pcmit is issued. I shall not mploy any ps$n in any mmns <br />s 6 to bccomc subjct to thc wor*m' compqsstion laws of Califomis. ud agre lhat if I should bccome subjat to thc <br />workm' compmation provisioD of Seclion 3700 of lhc Labor Code I shall. forlhrvith comply rvith lhos prcvisions.. <br />IVARNING: Failurc to wuc rvorkss'compmslion covcmge is unlawfil. ud shall subjat il mployfi to siminal psultiG ud <br />civil fincs up to one hundred lhosud dollm ($100.000). in addition to lhe cost of compeNation. dmage u providcd for thc <br />Sectiut 3076 ol l-ahrr inttrGt and atlorney s fc$. <br />I hcrcby affirm under poahy of pedury that I am licosed unclq 9 (cornmocing rvith Scction 7000) ofDivision 3 <br />of thc llusinss md Prefeiom Code. ad Iny licqsc is in full force ild ellst. <br />o 7z/?eOLiccNe <br />Drae: <br />Nunrhtr: <br />/t ( onlr{clor: <br />CONS'I'RU('TION I,ENDING AGENCY <br />I hcreby afllrn rnder lEnalty ofpqjury lhal lhtre is a conslnrcti()n lordirrg agmcy ftrr lhe poforrnance oflhe s'ork for shich this lunit is <br />issucd (Scc. .1097. Civ. C.). <br />lrndq's Nmc: <br />- <br />I-mder's Address: <br />APPI,I('AN'I' I)T]('I,ARA TION <br />I hor{ry allinn under penalty of perjury onc of the fcrlkru ing declarat ions: <br />I)cmrlition l'ermits-nststos Nolification Fcdcral RcSulati{)ils ( I itlc 40. l'arl6) <br />Rcqu ir cd t-cll$ of Notillcalion <br />_l cdiry thd the fedsal regulatiom regrding cbctos rmoval are not applicsblc lo this prcjcct. <br />- I cdify that I havc rad this application ed stalc lhal lhc ahotc infomation is corccl. I agre lo comply wilh all City and County <br />ordinancG md Statc tjws relating to building construclion. od h6cby authorize reprBmtativc of this City ud County to mtq upon lhe <br />above mmtioncd propcny for impcction <br />Applicant or Agent <br />z/_ <br />Pflnite nanle (prinl): <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openinqs <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />FinalTest <br />Meter Release I <br />FINAL z /z?/zrl -.t *{/.",1 <br />Notes, Remarks, Etc.r--4 a