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MECHANICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hacby alfirm unda pmalty of po'jury thal I m crmpt from the ContmdoE' LicGc Law for thc follorving remn (Se.7031.5 <br />Businss and Profsion Code): Any City or County which rcquire a pomil to comtruct. alta. improvq dcmolish or rcpeir any' <br />slructure. prior to ils isuance. also require thc applicant for such pemit to filc a signcd statmot that he or shc is lic6*d puNuut <br />to thc provisioG of the Contraclor's Liccnscd tarv (Chapt6 9. Commcncing with Scction 7000 of Division 3 of thc Buinm and <br />ProfessionsCodc)orthath€orshcisexcmptthqcliornandthebroisfortheallegedexmplion. AnyviolationofScctionT03l.5byany <br />appticant for a pmit subjects the applicant to a civil penalty of not more thm five hundred dolltrs (5500). <br />-1. <br />I owns of thc ptrop€rty, or my cmploye wilh wagc o their sole compmation. will do thc wort md the structm is not <br />intmdcd or offqcd for elc (38.7044. Busine ud Profeiom Codq Thc Contraclor's Licosc law do6 not apply to il ou,no of <br />thc property who builds or improvs tluotr and who do6 such *ort hiruelf or hwlf or thrcugh his or h6 om mploye6. <br />providcd thal such improvffits rc rct intodcd or oflqcd 6r sle. lf. howd6. the huiHing or impror'fiEnt is rcH wilhin onc )a <br />ofcomplaion. thc Oun6 Buiklc will have thc hrdm ofproviog thd he or shc did rct build or improrr fie prcpqty for thc purpos of <br />sh). <br />-1. <br />s omo of thc propcty. m exclusively contracting rvith licmsed contracloE to conslruct thc proj(t (Sa. 7044. Bwines <br />md PrcfissionCode:ThcContractor'sLicenseLawdo6nolapplytoanowncrofpropcflyrvhobuildsorimprovsthcrcon. <br />and who conlracts for such projects with a Contnclo(s) licmsed puBuilt to lhe Contractor's Licmsc Law). <br />I ilrrt crctDll urrdcr Scctiorr . l). & l'.( . li)r lhis rcns()il. <br />()$ner: <br />rvonxsns' c'oi\rpsxsfl i()N <br />DECLARATION <br />I hoeby affim unda pcoalty ofpojury one oflhc following daluatioro: <br />-l <br />havc and will maintain a C€nifrcalc of CoGfit lo Sclflmure for rwrkc' comperoaion. u pretidcd for by S6tion 3700 of thc <br />labor Code for thc pcrfomuce of the work for which thc p6mil ir isued. <br />the <br />hareandrvillmaintainworkqs'compemationinsurance.6 requiredbySrclionST00ofthet,aborCode.forthepafomanccof <br />work for N,hich lhis pennit is issued. My cornpensation insurance can'icr md policy nrrnbcr uc: <br />tt/t * <br />Policy <br />-l <br />certiry that in thc pafomance of thc work for which this pqmit is issued. I shall not onploy any pssn in sny mmn( <br />* c to bccomc subjct to the $od(6' comp€nstion las,s of Califomia. and agre that if I should bccomc subjm to the <br />*ork6' compen$tion provisioro of Section 3700 of thc Lsbor Code. I shall. fonhwith comply with thos prcvisiom.. <br />WARNING: Failurc lo sure Norkqs' compo$lion covmge is unlarvful. and shsll subjst m mployu to oiminal poahie and <br />civil fines up to one hundred thousud dollaB ($100,000). in addition to lhe cost of cornpcnsation. dmaga o providcd for the <br />Seclion 1076 ofthc inlere( and athmsy's fe6. <br />LI('ENSED CON'I'RA("TOR <br />DECLARA'I'ION <br />I hercby aflirm undo penalt)'ofperjur.v thal I an licersol undo Jrovision of('hapls 9 (conxnencing vilh S(lion 7000) ofl)i\ ision 3 <br />of lhe l]usinss and Profssions Code. md mr license is in frrll force od effst. <br />ba7 ?g=License Numbo: <br />( otrlrtrclor: <br />- <br />CONS'TRUC'I'ION LENDINC ACEN(:Y <br />I hoehy aflirm undo penalty of periurf that lhs'c is a conslruclt)n lendirrg agency- for thc psfonnailce ofthe \york for s,hich this fmnit is <br />issued (Sec. .1097. ('i\,. (-.). <br />Lend$'s Namc: <br />tands's Addrs: <br />APPLICANT DECLARAl'ION <br />I haetry allirrn under poalty ofperjury one ofthe follo\r'inB declarations: <br />Demolilion Permits-Asbstos Notification lfederal Regulations ('t itle 40. Par16) <br />Required l.elts of Notification <br />I cdify that lhe fedsal regulations regoding ubolos rqnoval are nol applicable to this prcjst. <br />I cgtify lhat I havc rad this applicalion ild statc that thc above infonnalion is corect. I agr€ to comply with all City and County <br />ordiranc6 ud Slatc IAvs rclating to building construction. and hscby authorize reprBmtalive ofthis <br />abovc mdtioncd prclEfly for <br />Applicot or Agot Si8nsturc: <br />Pmile nanc ( <br />_ Datc:);i/z* <br />Appliances <br />lVletal 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 />Final Test <br />Meter Release It J r,? <br />FINAL v q /0 uu ttu *r -/ <br />Nofes, Rpmarks, Etc. , <br />k €(Ls Lr*tt <br />I <br />I <br />Carier: