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M ECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COM]ViENTS Own6-Buildcr Dcclsral ion <br />I heteby affirm undcr plnrlty of perjuty lhat I sm cxcmpt form the Contrsdors' License Law for thc followinS r@son (se.7o3 1.5 B6in6^r <br />md Profcsion Codc)r Any City or Counly which rcquiro a pmit to coNtruct. altcr. improvc. dcmolish or rcprir uy siructuc-. prioJ ro its ! <br />issuncc. also rcquirc thc Epplicstrt for such pcmh to filc a signcd stEtemcnt that hc or ahc is liccrucd punuut to thc p@r'isii* oLlc <br />Contrsctor's Lic€6ed Llw (Chspter 9, Commcncing with Saion 70OO ofDivbion I ofthe Businrs and Profesio$ Cod.) or thlr.hc or <br />Ehc is crcmpt thsc&om and thc b6fu for thc sllcgcd cxcmption .Any violation of Scction 7031.5 by my rpplicail for I p€mil subjcls thc <br />applicant to a civil pcnalty ofnot morc than fivc hundrcd dollm ($500). <br />a <br />_1. $ owncr of thc propcriy. or my cmployco with wagcs as thci, solc compcnsation. will do thc work and thc structuc is not intcndqd <br />otoffcredforule(Sec.T044.BusinssandProfcsrionsCodc TheContractor'sLicenscLawdoesnotapplytoanomerofthcprcpdly <br />who builds o, imp.ov6 thd@n. md who do6 such work himsclf or hmclf or through his or hs own cmploycs. providcd that such <br />imprcvcmcnts ue nol intcndcd or offqcd for salc. lf. howcvcr, thc building or improvcmcot is sold within onc ycr ofcomplaion. thc <br />Owofi-Builds will h.vc rhc bwdcn ofprovitrg that hc or shc not build or improvc for thc purposc ofralc). <br />_1. I owns of thc propcty. am cxcluivcly contraciif,g with liccNd contmctoE to coGtruct thc prcjcd ( Sc. 7M4. Buinas md <br />P.ofcasion Codc: Th. Contr.dor's LiccNc [rw do6 not lpply to e owffi ofproprty who builds or improvcs thssn . and who <br />contracls for suqh projccis with 8 Contractor(s) liccnscd pursuant to th. Contruclor's Licensc kw.). <br />I flrn c\crDl)l {rndcr Sccli,rn .l} & l} ( li)r lhis rcason <br />I)ste:( \\ I(r <br />WORKT:RS COIIPENSA'IION DECLARATION <br />I hcrcby aflirm undcr pcnslty ofperjury onc ofthe following declralions: <br />_l havc and will maintain a Ccrtificatc ofConscnt to Sclf-lBure for workers compensation, as provided for by Section 37OO oftho <br />labor Codc, for thc pcrfomancc ofthe work for which thc permit is issued. <br />_l have and will maintain workets' @mpcnsation iniursnce, 6 required by Section 3700 ofthe lJbor Codq for the perforroncc ofthc <br />work for which this permit is i$ued. My workers' compcn$ton iNursnce orricr and policy numbcr arc: <br />('mier; <br />Policy l.rpir cst <br />('l his section nced not be completed ifthe perrnit is lbr One hundrcd dollars {$I001 or less) <br />.,_l ccfrify lhat in the pcrl'urnance ofthe work for which Ihis pennit is issued. I shall not employ a,1) pcrson in any manner so as Ir <br />becamc subject nr the workcrs ' conlpenslron larvs of ('alifornia. and agree lhnl rf I should beconr suhJecl lo thc workers' <br />compcnsation ofScction -1700 ofthc kbor Codc. <br />WARNINC: Failure to secure workers' compensation coverage is unlawful, and shall air emplover to criminal penalties and civtl <br />fincs up to onc hundrcd tho6and dollm ($100,000),in addition to the cost of <br />the Lsbor Code, interest and sttorney's fees. <br />damages d providcd for the Section -1076 of <br />LICENSED CONTRACTORS DECLARATION <br />I hcrcby affm udq pcmlty of pcrjury rhat I m liccnscd unds provision of Chaprcr 9 (comencing wirh Scclion 70OO) of Division 3 of <br />thc B6ine$ and ProfosioN Codc. 8nd my liccNc is in full forcc md cffect. <br />Liccmc Liccnse Number I <br />Dste: <br />I hcreby affim under penalty ofpcrjury that thcrc is a co$lruction lending agcncy for thc pcrfonnancc ofthc rvork for which this pcmit is <br />issucd (Scc. 3097. Cn'. C.). <br />Lender's Name: <br />Lender's Address: <br />APPLTCANT'S DECLARATION <br />Dcmolition Pemits.Asbcstos Notification Fcddal Rcgulations (Titlc 40. P8n 6) <br />_ Rcquircd lrttcr ofNotilication <br />_l ccnify that thc fcddal rcgulatioN rcg.rding sbGtos removal arc not .pplicablc to this prcjmt. <br />_ I ccniry thd I havc rcad lhis applicstion md shtc that thc abovc information is corcct. I agrcc to comply with sll City and County <br />ordinancs and Ststc Lsws rclating to 8uthorizc rcprGentatilcs ofthis City and County to mlcr <br />above mentioncd prope(y for <br />Applicant or agenl <br />Pennillce name (print)i <br />and <br />o OZ <br />upon lhc <br />Appliances <br />Metal Fire Place <br />Evap Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors I nstalled <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 />Rough Mech <br />Final Test <br />Meter Release A <br />FINAL L/*4/t/,VU/, /)rnnhd t/ / w V-/ <br />Forms\Mechanical-lnspector Record.doc 03.3,l.06