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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS oWNER BUII,I)I:R DI,]I,CARATION <br />I hcrcb], afllrnl undcr pcntlty ol pcrjury lhrt I nrr cxertln liom lhc Conlrrclors' [-iccnsc Law li,r lhc fi)llowirlg rcason (Scc.?0J1.5 <br />Busincss nnd Prcfcssion Codc): Any City or County which rcquircs n fcrnrit lo conslrucl. rllcr. iilrnrovc. dcnmlish or rcprir any <br />\truclurc.priork)its issudncc.nhorcquirc\thcapplicanlli)rsuchlErnlilk)filcasigncdsl{lcnrnl lhrlhcorshcirliccnscd pursulnl <br />to rhc provi\ions of lhc Contracklr's l-iccnscd lrw (Chaplcr 9. Coilrtrlcncing wilh Scction 7(X[) ol Division J of thc Busincss rnd <br />l,rolcssk)nsCo(lc)orthuthcorshciscxcnlplthcrcliomandthchrsi*li)rlhclllcgcdcxcmption. Anyviolxti()nofSeclionT0]l.5hyany <br />nfplicrillli)rilFrmilsubjccl\lhc dpplicanlktacirilpcnaltyofnoltrx,rclhlnt]vchundrcddollilrs(S5{X)). <br />l. as trrvncr ol thc p(rpctry. or nry t'ilrplryccs with wagcs rs lhcir yllc coiUcnsrlion. \ ill (l(r thc $rt'k ind thc slrtturc i\ lxi <br />srlc). <br />_1. as ownc. of the pmpeny. am cxclusively cont,acling with licenrcd conlmctoN to construct thc pmitt (Se. 7(X4. Busimss <br />ard Pmfssion Codc: The Contractor's Liccnsc Law d@s not apply to an owncr of protEny who builds or improves lhetcon. <br />and who contmcls for such pojccts with a ConlEcto(s) liccnsed pursuanl to the Contractor's Licen* kw). <br />llnrcxcnrp|Undcrsccli()ll-.I],&P,C.li)rlhistcnson. <br />I)sle: <br />WQBtrEBLI;QDISENSAIION <br />DECIIIEAIIQN <br />I hcrchy alfirnr unrlcr pcnall y of F-rjury onc of lhc following dcclxrtl krts: <br />_t halcnndwill minlainrCcnillc0tcofConscntk)Sclflnsurclor\orkcrs compcnsalion.n\ providcdlbrbyScclk)n-17U)oflhc <br />Latxrr Crxlc. lirr Ihc pcrlorftrncc o[ thc work lhr which thc pcrmit is irsucd. <br />_l hrvc nnd will nrilintain worken' c(rnpcnsalion insurancc. ns rcquircd by Scclion 3T(X) ol lhc l.uhor Cr)dc. for lhc pcrk)rnmncc of <br />lhc work li)r which this pcrntil is issucd. My workcrs' coilrpcnsatk)n insurancc ctnicr and g)olicy nunrhcr trc: <br />Policy Numbcr: ExPircs: <br />_l ccnify that in the [*rformance of lhc work for which lhis pcrmit is issucd. I shall ret cmploy Bny pcrson in any msnnct <br />s as to bccom subFct lo thc workcrs' compcnsation laws of California. and agrc (hat if I should bccom subjcct to thc <br />workcrs' compensation pmvisions ofScction 3700 oflhc Lat[r C:odc. I shall. fonhwilh comply wilh thos povisions.. <br />Srrlion .]()7(r ol lhc l.ahrr Crxt'. irrlrrcsl :ln(l xll,rr[Y s lcc\ <br />l)alr: <br />LICENSED C()N'I'RAC'TOR <br />D1.]CI,ARA'I'I0N <br />(,l lhc llu{incs\ rnd Prrl'cssionr (ixlc. utl nly liccnsc is in litll lirrcc xnd clltct. <br />Liccnsc Class:-l,iccnsc Nuillhcrl <br />l)ate: Contraclor: <br />W <br />I hcrcby alfirnt lndcr lEnalty of pcrjury thot thcrc is a cof,slruclion hnding agcncy for lhc pcrfornuncc of lhc work for which lhis frrnlil is <br />issucd (Sec. 1097. Civ. C.). <br />l,cndcr's Nlrnc: <br />kndcr's Address: <br />AfILII;ANI.DECLABAIII'N <br />I hLrcbyallirmundcr pcnalty ol t^-rjury onc of lhc tbllowiiS dcchrdlk)ns: <br />I)cnxrlition [,crnril\-Asbcstos Notificatkn Fcdcral Rcgulations ('l illc.l0, Pafl(]) <br />-Rcquircd <br />Lctlcr of Ndificalion <br />-l <br />ccrtily lhilt thc ltdcral rcgulrtions rcgilding ackLsb\ rcrn(t!rl rrc rril illPli(ilhlc lo this proiccl. <br />iltr)1'c nrcilli()nc(l p()l)cdy lor inspcclioil purF)sc{. <br />Applicrtrl or Agcnl Signxturc:_ Dalc: <br />Pcnnilcc nrnrc (prilil): _- <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />lvlisc. Equipment <br />Duct Work <br />Pre-lnsulation <br />llsulation <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 />t <br />Rouqh Mech.7112,/zcr,,ts -<V,4n <br />FinalTest ( <br />Meter Release <br />FINAL lol tzla)urlrbc <br />Notes, Remarks, Etc.