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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hrcby affm uoda poalty of pcjury that I m crcmpt from thc ContructoB' Licens tlw for thc following r.&n (Se.7031.5 <br />Buines ard Profcssion Codc)l ADy City or Couty which require a po'mit to coEtrucl alto, improvc. danolish or repair my <br />structuc, prior to its isswcc, a.lso requLe thc applicmt for such pcmit to file I sigtrcd stat@6r thd hc or\hc b licascd puaua[t <br />to thc prcvbiore of the Contractor's Lien*d L:w (Chapt6 9, Commmcing with Scrion 7000 of Division 3 of thc BBin6s.fld <br />PrcfsiomCodc)orlhathcorshcisexmptrhqcfromudthcbasisforthcallcgcdampion. AnyvblatiooofSctionT03l.5byuy <br />applicelforapcmitsubjststhc appticettoscivilpcmltyofnotmorcthmlivchuodreddollm($500). <br />Nt. ^ o*", of ,tre propqly, or my cmployc with wag6 6 their slc compstsolioo, wi.ll do the wqk md the structue is not <br />intddcd or offqcd for slc (Sc.7044. Buios od hofeioN Codq Thc Contrsctor's Lic@ trw doe not qply !o m omq of <br />thcFopqty whotuildsorimprovcths@&edwho&6suchrcrthimsclforhGclforrhrcughhisorhcomanployc, <br />provided that such improvamts re rct iilotdcd or ofrqcd for slc. lf, howd6, thc tuildirg or irprorlomt is sld withio onc )@ <br />of compl*ion, thc Owna Buikkr will have thc hrdo of prcving thd hc or shc dil mt build or iDprow thc pmpqty for the trrpoc of <br />slc). <br />t <br />_1. 6 om6 of thc prcpGty. m qclBivcly corffacling with lic@cd contractoF to construct thc trojcct (Sc. 7044, Buils <br />od Profusbo Codc: Thc Conlractor's Licasc Law doc not apply to m ownq ofpropcrty who builds or improvs ths6n.and who coffracts for such proj6ts with a Contacto(s) ticfficd pusuot to thc Contractor's Licffc Low). <br />-l <br />m cxmpt uda Sation , B. & P.C. for Ois rwn. <br />oetc: I 3 / s /zo **'lJ, %l,ra A. /L---t--77- @ . DECLARATTON <br />I hceby aflim unda pcnalty of pojuryone of lhc followhg delaations:7 <br />_l have ild will maintain a Certificate of Consent to Sclf-lnsure for rvorkers' conrpensalion, as Fovided for by Sstion 3700 of thc <br />t,almr Code. for the pqfirnnancc of the rvork for which the pmit is issucd. <br />_l have and ryill maintain rvorkers compeNalion insurance. m required by Setion -3700 ofthe l,abor Code. for thc pgfomancc o[ <br />the uork for uhich this pflnit is issued. My workers cotnpenstion insurmce cmier md policy nurnbe ae: <br />Policy Numbe: Erpires: <br />-l <br />certiry that in thc psfonnance of the work for which this permit is issued, I shall uot mploy any p€Bon in any mmner <br />s 6 to become subjst to the work6s' compastion laws of Califomia. ud sgre that if I should becomc subjat to the <br />wortqs' compwtion pmvisioru of S{tior 3?00 of the Labor Code. I shall. fonhwith comply with thos prcvisiom.. <br />WARNING: Failure to sue workm' compcrsation covcrage <br />civil fine up lo ooc hundred thomd dollm ($100.000). in r <br />is unlawful. ud shall subjst m mployr to qininal p68ltics ild <br />addition to the cost of compeNatioo. dmag6 c providcd for thc <br />S(tion 3076 ofthe t bor Code, intsGt ild atorney's <br />I,ICENSED (]ON'I'RA(''I'OR <br />DECLARA I'ION <br />I hcby affm uodc pcnalty of pqjury that I m licascd mda prcvision of Chaptq 9 (commcing with S€rion 7000) of Division 3 <br />of thc Bsins ed PrcfsioN Codc. ed my liccrc is itr full forc md cflcct, <br />Liceroe Clus:-License Number: <br />- <br />Dste: ('onlrrctor: <br />CONSTRUCTION I FNDINC ACFNCY <br />I hrcby affirm unda penalty of pqjury that th6e is a coNlrudion lmding agocy for lhe psfomoce of thc uork for which this pqmit b <br />issued (S(. 3097, Civ. C.). <br />l,ender's Name <br />[-ender's Addr6si <br />APPI lCANT IIRCLARATION <br />I ho@a.6m undo penalty of ptrjury otrc of thc following drclamtions: <br />Dcmolition Pmils-AsbBtos Notificalioo Fed@l Regulatiom (Titlc 40. Pan6) <br />-Requircd <br />t ttrof Notificatiotr <br />-l <br />cqtify that the fcdad regulatio$ rcgading sbeslos rmoval ae not applicable to this prcjcd. <br />is conet. I agre to cornply <br />I reprGentativB oflhis City <br />with all City and County <br />md County to mtq upon the <br />Applicilt or AEot *.,\/y'zu <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 />Openings <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rouqh Mech. <br />FinalTest 4 <br />Meter Release \.\\r'Ith <br />F!NAL v ,H0'rup DlvllY)fU'l ir\D <br />Notes, Remarks, Etc. <br />on", ( 3r/qr/zo <br />Pffiiten?@(w)ri/-7