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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hocby affrm und6 pcf,alty of p€rjury that I m crcmpt fipm the ContracloB' Liccrc Larv for thc following rcen (Ss.7031.5 <br />Buines and Profasion Codc): Any Cily or Counly which requirc a pcrmit lo corutrucl. alt6. improvq dmolish or rcpair mf <br />structuq prior to ils isumce. also requirB lhc applicsl for such pemit lo file a signcd statemmt that he or she is licmsed pmwi <br />to lhc prcvisiore of thc Contractor's Licensed Law (Chaptq 9. Comencing with Sstion 7000 of Division 3 of thc Busine and <br />Profc$ionsCodc)orthathcorsheiscxcmptthdcfromudlhcbasisforthcallegcdcronption. AnyviolationofScctionT0ll.5byuy <br />applicmt for a pcmit subjsts the applicilt to a civil penally of not morc thu five hun&cd dolles ($500). <br />-1. <br />c owna of lhc prcpsdy. or my cmploye with wage u their slc compruation. rvill do thc rvork md the structwe is nol <br />intoded or offscd for slc (58.7044. Busins and Profsions Codq The Conh actor's Licose Law do6 not apply to an om6 of <br />lhe Eopsty who tuilds or imprcve th6@n. ild sho do€ such w* himsclf or hmelf or through his or ho orn employee. <br />providcd that such improvqMts e rct intadcd or offqcd for sle. If, howws. thc hrilding or impovmor is wld rvhhin onc )s <br />ofcompkilou thc Ouna Buiktq will havc thc hrdo ofporing thal he or shc did mt tDild or imprcvc thc propqty for thc purpos of <br />$lc). <br />-1, <br />r omc of thc popcny. m cxcluivcly contracting with liceB€d conlracloG to construct the prejst (Sc. 7M4. Btsine <br />md kofusion Codc: Thc Contractor's Liccnsc Law doo not apply to m owno ofpropcrty who builds or irnprov6 thersn. <br />and who contracls for such prcj(ts with a Contmcto(s) lic$ed pu6@t to the Contractor's Liceroe Larv). <br />-l <br />tun exempt under Section _ _ , B. & P.C. for this rereon. <br />Owner: <br />WORKT]RS' CONIPENSAI'ION <br />T,ECLARATION <br />I hereby allirnr undr poalty ofpojury one ofthe follorving dalaations: <br />-l <br />hat'c ad rrill maintain a Cerlificate of Consent to Self-lnsure for *'orkm compensation. s prorided for by S*tion 11700 of thc <br />tibor Codc. for lhe pqfonnance ofthc rvork for $'hich thc pfinit is issued. <br />I have and will mainlain rvorkos' compensation insumnce, 6 required by Set ion -i700 o f the t,abor Code. ftrr the poftrnnancc oi <br />the work for which this pmnit is issued. My workds' composation insurance carier and policy number are: <br />-t <br />cotiry that il thc poformancc of thc work for which this pemit is issucd, I shall not onploy any pmon in any manncrs uto beomc subjcl to thc wortc'compcnslion laB of Califomia. and age that if I should bccomc subjtrt to thcwort6' @mpcnslion prcvisioro of Scction 3700 of lhc Lsbor Codq I shall. fonhwith comply wilh tho* prcvisioro.. <br />WARNINGT Failure to scuc workm' @mpmsation covmgc is unlawful. and shall subjat o anployc to oiminsl fEuhica ed <br />civil fina up to one hundrcd thownd dollm ($100.000), in sddition to thc cost ofcompcnsation, damagcs as providcd for thc <br />Sction 3076 of thc Lsbor Code intqst and attomry's f6. <br />4r,) -72, <br />LICENSFN CONTILI.CTOR <br />DECI.ABAIIO! <br />I heby affm udc panalty of pcdury thd I m liccnscd uda prcvisioD of Chaptq 9 (@mmocing with Sqtion 7000) of Divisio! 3 <br />of thc Bwitw ed hofeiom Codc, and my liccc is in full forcc atrd eff6t. <br />Licmc Numba: <br />CONSTRUCTION LENDTNC AGENCY <br />I hmby affim undo pct alty of psjury that thqc is a construction lcnding agocy for thc pcrfor:mcc of thc woft for q,hich this pqmit b <br />issucd (Sc. 3097, Civ. C.). <br />I crrdcr's \;rrnc <br />Lendq's Addrs: <br />APPLICANT DECLARATION <br />I ho*y afnn uoda pcnalty ofpojury otre ofthe following delantions: <br />DeEolitio! PmiB-Asb6tos Notification Fcdqal RcgulatioN (Titlc 40, Pa!t6) <br />-Requircd <br />Lctts of Notificarion <br />-l <br />catify that ihc fcdsal rcgulatioN rcguding ubctos rmoval ue not applicablc to this prcjEt. <br />-l <br />cGtiry that I havc rad this application ed ststc thst thc abovc infomation is cor$t. I rgrc to comply \ ilh all ('ity flnd ('ounty <br />ordinancB and Statc Larvs rclating to building construction. ed hseby aulhorize repraotaliv6 ofthis <br />abovc mmtioncd prclErty for <br />Cily ud County lo ols upon thc <br />purposG. <br />Applicmt or Agilt () <br />I )xtc <br />Pmitcnmc( <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace a <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />I I I i <br />Rough Mech.tlt2.W Wlt)lvl,{ <br />Final Test I I <br />Meter Release rl il <br />FINAL /r//tvl <br />Notes, Remarks, Etc.,l <br />./n/ -/.t-;/r'/ <br />I ll,l tll+ <br />'Z- Z'l / <br />Policy Numbcr: l:rpircs: <br />contrctor,W