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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/S!G COMMENTS OWNER BUITDER DEIf,ARATION <br />I hcby alfim un&r paalty of pajury tha I m qarpt ftom rhc Coilnclon' Liccnrc kw for the following rcn (Se.?031.5 <br />Buincs md Prof*ion Codc): Any City or Coutrty whkh rcquic a panit to cooltruct. 8lta, imprcvc. danolish or EDsir sy <br />structue, prior to ir3 isurec, also rcquiro thc Qplicut for such p€ndt to filc I sigrcd statffit thal hc or slE i! licdscd pwatll <br />to thc prcvisioG of thc Contretor'! Limrcd Lrw (Chapr 9. Comming with Setiotr 7000 of Divisba 3 of tbc Busirc ed <br />Profeiou Codc) u that hG or shc b q@fl thsc&om dd thc bssis for thc d@cd amption. Any violaioo of Sdion 7031.5 by ttry <br />applimt for a pamh subjets thc applicrnt to a civil pmlly of not morc the fivc bundrcd dollm ($500). <br />_1. I om6 of thc propatn or my cmployE with w8g6 I their mlc ompcroaion, will do thc wort ad thc ltnElrc is not <br />intadcd or offcrcd for slc (Se.7044, Buine ud Pro&ssiom Codc: Thc Contnctor't Lic€E [:w do6 not apply to e om6 of <br />thc proFty wto br|ilds or imprcu tlsoc ed who dG sh w* hiruclf or h6sdf or thrcsgh hi! tr h6 om cmploycc, <br />provid€d thsr such impomcrls rc mt iotodod or ofutd for slc. lf. ho*cE, thc hrfiiry or inprowl b rH wilhin orc )q <br />of onpl*bo. ttrc Owur Builda uill harc rhc hrda of proviog tha hc or shc di, mr hild or imFoc ttc popcty 6r thc FEpo$ of <br />$h). <br />-1, <br />I oms of the pmpqty. m qcluivcly @ntr&titrg with licoscd cotrtracton to @nstruct thc proj61 (Sc. 7044, Bcins <br />ad Poftsim Co&: ThG Contnctor'! Licffi kw doB not apply to e own6 of prcpcrty who builds or imprcvG thgan <br />ud who ontracls for sch pmjEl! with E Coolreto(3) liccEcd pswt to 0E Contnctq'! Licre Lrw). <br />-l <br />m cxmpt ud6 Sclion-, B. & P.C. for this wn. <br />I hereby affrrm under penalty <br />-l <br />have and will maintain a Certificate of Conseot to Self-lnsure for workers' compensation, as provided for by Section 3700 of the <br />labor Code. for the performance of the work for which the pcrmit b issued. <br />-l <br />have and will maintain workers' compensation insurance. as required by Section 3700 of the tabor Code, for the pcrformurce of <br />the work this p,ermit is issued.carrier and policy number arc: <br />Policy <br />_l certi& that in the performance of the work for which this permit is issued. I shall not ernploy any person in any manner <br />so as to become subject to the workcrs' compensdion laws of California. and agree thd if I should bccome subject to the <br />workers' compcnsation provisions of Seclion 3700 of the Labor Code. I shall. forthwith comply wilh thosc provisiotls.. <br />WARNING: <br />civil fines up <br />Failure to secure workers' compensation coverage is unlarvful. and shall r <br />hundred thousand dollars ($100.000), in addition to the cost of <br />subject an employet to criminal panalties and <br />damages as provided for the <br />Section 3076 Code. interest and attorney's fees. <br />C <br />I ICTNSTiD CON'I'RA(:'I'OR <br />DI'CLARA'I'ION <br />I hereby affrm under penalty of perjury that I anr licerued under p,rovision of Chapter 9 (commencing with Section 7000) ofpivision 3 <br />of the Business and Professions Code. and my license is in full force anrJ effect. . <br />CLicense Nurrrtrcr: <br />ZO contractor: <br />W <br />I hrcby alfrnr unda padty of pcjury thd th@ is s ondructbo lcoding agcy for thc pcfoIrroce of thc mrl br uhkh this pamt b <br />issucd (Se. 3097, Civ. C.). <br />l'ender's Address: <br />Arr, ,.ANT DEC <br />I herdry affrnn under penalty of pojury one of the follorving declarations: <br />Demolition Pennits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />-Required <br />Letter of Notification <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />Insulation <br />Smoke Detectors I nstalled <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type Il 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 ll A <br />FINAL t&2t20 lWtltm YIA <br />Notes, Remarks, Etc.I <br />-l <br />csrify thd rhc fcdaal regulatiom rcgading ubetos @oval re not applicablc to thb Foj€{. <br />fun r r^ ,*c red this spplication atd statc rhat rhc abovc infonf,arion is coret. I agrts to omply with all City atd county <br />fordfiurcc md Statc L8w rclding to building constructiorl md h6c^by authorirc rc?rMtativ6 of this City ud Co.unty to cqts upon thc <br />abov€motiotrcdprcpsryforiroparioqffi)s. , t L <br />Appitco,orAsars,r,*,*, ffP& 4a/r{t ^,. b/zl/lo <br />Pmilemc(Fmt, y'l.Zq qA;tA t