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a <br />MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNERBUILDERDELCARATION . f <br />I hercby 8fftrm uriler pcnslty of pcrjury that I m exempt fiom thc ContrctoE' Lkens law for the fotlowing rca6n (Scc.7031.5 <br />Business atd Prcfession Codc): Any City or County which reluircs 8 pcmit lo onstret, dls. imprcrc, demlirh or rcpoir my <br />struclurc. Fior to ils issuare. also rcluircs thc applicst for such Fmit to fih q sigred ststemnt thst he or slrc ir liensi p|msil <br />to thc prcvisions of thc Contrsctor's Lkrtrsed llw (Chapter 9. Comercing with Sstion 7000 of Division 3 of th€ Busircss and <br />PmfcssionsCode)orthathcorshcisexemptthrefromandthebssirforthesllegcderemption. AnyviolationofSectbnT03l.5byany <br />rlrplicant for a pcrmit subjccts lhc spplic8nt to 8 civil penalty of not mrc than five hundrcd dollss ($500). <br />-1. <br />as owner of the profrcrty. or my employecs with wagcs as thcir solc compcnsation. will do the work and thc structure ls not <br />intended or oftbred for salc (Scc.7044. Business and Professions Codc: Thc Contractor's Licensc l-aw docs not apply to an owncr of <br />the propcrty who builds or improvcs thcrcon. and who does such wo* hirnsclf or herself or through his or her own employecs. <br />providcd that such improvcnrnts are not intcndcd or offercd for sah. ll. howevcr. the building or impmvenrnt is sold wilhin one )rar <br />of completion, the Owncr Buildcr will havc thc burden of proving that hc or she dkl not build or irnpmve thc proSroty for thc purynse of <br />sBle). <br />-1. <br />as owner of thc property. am cxclusivcly contracting with liccnsed contractors to construct the project (Scc. 7W. Business <br />and Profssion Code: Thc Contraclor's License Law does not apply to an owner of properly who builds or improves thereon, <br />and who contracts for such projccts with a Contractor(s) licenscd pursuBnl to the Contractor's Liccnsc Law). <br />-l <br />arn cxenlpt under B. & P.Cl. lirr this rcason. <br />Owner:_ <br />WORKERS' COMPENSATION <br />DF'CI-ARATION <br />I hcrcby affrm under pnalty of perjury onc of thc following declarations: <br />-l <br />have and will maintain a Ccrtificate of Consent to Self-lnsurc for workers' compensation. as provided for by Section 3700 of the <br />l^abor Code. for the performance of the work for which the lrcrmit is issucd. <br />-l <br />havc and will maintain workers' compensation insurancc. as requircd by Scction 3700 of the Labor Code. for the performancc of <br />lhe work this pcrmit is issucd.ronllcnsaliorr irrsurarrcc carricr and policy rnrnrbcr ilrc: <br />Policy <br />-l <br />certify that in the lrcrforrnancc of lhe work for which this Jrcrmit is issucd. I shall not employ Bny person in any manncr <br />so as lo becomc subjcct to thc workcrs'compcnsation laws of California. and agrcc lhat if I should bccornc subjcct to lhc <br />workcrs' compcnsation provisions of Section .i700 of the [:tnr Codc. I shall. forthwith comply with thosc provisions.. <br />WARNING: Failurc to sccure workcrs'compcnsation coverage is unlawful. and shall subject an cmploycr to criminal penalths and <br />civil fines up to onc hundrcd thousand dollars ($1O0,ffDt. in additicln to the cost of compcnsation. damagcs as provided for thc <br />.Scction 3076 of thc Code. inlcrcst und altorncy's fccs. <br />LICENSED COT{TRACTOIT <br />DT'CLI\RATION <br />I hcrcby aflirm under pcnalty of perjury that I am licenscd under provlsion of Chapter 9 (comnrcrrcing with Section 7m0) of Division 3 <br />of the Business and Professions Code. and my license is in full forcc and effect. <br />G LLicenseNurnhcr: <br />W <br />I hcrcby 8ffrm under pcBlty of Fdury thst thcrc is a @nstruction bndiog rgsrcy for thc pqfm of tlE work for whhh thii p6mn is <br />issucd (Sc. 3097. Civ. C.). <br />[.rdtr's N8m: <br />lrnder's Addrcss: <br />APPLICAN'I' DTCI,TRA'TION <br />I hcr""by allirrrt undcr pcnllty of'pcrjury onc of thc following dcchral iorrs: <br />l)cnxrlition Pcrmits-Asbcstos Notil'icalion Fcdcral Rcgulations ('l'itlc 40. Part6) <br />_Rcquircd Lctlcr of Notitication <br />-l <br />ccrtify that the fcdcralrcgulations rcgarding asbcstos rcnmvalare not applicable to this proict. <br />-l <br />ccdify lhat I havc rcad this applicalion ard strte that thc aborc informtion is corccl. I agrc lo @mply with all City rnd County <br />ordinarccs and Stale kws rclsling lo building construction. ard hcrcby ruthorire rcprcscntatives oflhis City ud County to entcr ulrcn thc <br />atxrvc menlioncd propcrty l'or <br />Applicarrl or Agcnt <br />l)crrrtitc'c narrrc <br />,,$4f 1,)2a <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 Installed <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 At rTt <br />Above T-Bar ll'Y''40 lJ kz/&t bq00 <br />Rough Mech. <br />Final Test <br />Meter Release lA,/ <br />FINAL /1.29 'L0,I//5?Q Frt> <br />Notes, Remarks, Etc <br />l)nlc: <br />t <br />l)nlc: <br />1l)ale: