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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUtt,DER DELCARATION <br />I hcrcby afftrm undcr penalty of perjury lhal I m cxcmpl fmm thc ContracloF' Liccnsc kw for the following rcssn (Se.7031.5 <br />Busincss ard Profcssion Code): Any Chy or County whbh rcquires a ;rcrmit lo construcl. altca improve. dcmlish or rcIEir sny <br />strucnrrc. prkr to its issuance. also rcquircs lhc spplicant for such fErmit to filc a sigred statemnl that he or shc ir liccnscd purruant <br />lo the pmvisions of thc Contractor's Liccnscd ljw (Chaptcr 9. Commcncing with Setion 7000 of Division 3 of thc Business and <br />PmfcssionsCodc)orthatheorsheisexcmpttherefromsndlhcbasisforthcellcgcdcxcmplion. AnyviolationofsectionT03l.5byany <br />spplicant for a pcmit subjects lhe applicant lo a civil pcn{lty of nol more th0n fivc hundred dolltrs ($500). <br />_1. as owrer of thc pmlErty. or my employcs with wagcs as their elc compcnsalion. wiu do the wok ord the stnrtw Ls mt <br />intcrf,lcd oroffcrcdforsle(Se.T044,BusinessmdPmfcssionsCode:ThcConlractor'sLiccnrcljwdocsnotapplytoanowncrof <br />lhe pmFny who builds or inprows *E@n. ard who des such work himself or herself or thrcu8h his or hcr own employces. <br />providcd that such impmrcrents rc not intcndcd or offcrcd for salc. If. howcvcr, lhc buiuing or improvcmnt is sold within onc )re <br />ofcomphtion. thc Owncr Builler will havc thc buden ofpmving thal h€ or shc did not build or itnpmvc lhe prcFrty for thc purtns of <br />slc). <br />_1. as owrer of lhc prcpcrty. am cxclusivcly contracling wilh liccnsd contracbrs to construct lhc pmjcct (Ss. 7(}14. Busircss <br />and hollssbnCodc:ThcContractor'sLiccnscLawdocsmlapplyloanowncrofprofErlywhobuildsorimfrovcslhcrcon. <br />und who conlncts for such projects wilh a Contmcto(s) liccnscd pursuanl to lhc Contractor's Liccnsc [jw). <br />_l om cxcmpt undcr lr. & t'.C. lbr this rcr\on. <br />()ri ncr: <br />]UQSSEBLCQIIPJNIiAIIAN <br />DECI.ABAIIAN <br />I hcrcby iltfirm undcr frcnalty ofperjury one ofthe following dccluralions: <br />_lhqveardwill rointainaCenifkstcofconsnttoSclf-lnsurcforworkcm'comlEnstion.ss prcvidedforbySetion3T0Ooflhc <br />Labor Code. for the perfomrce of thc work for which thc pemit is issucd. <br />,H havc {nd will maintoin workcrs' conrpcnsation insurancc. as rcquircd by Seclion 3700 olthc lnbor Codc, for thc psformncc of <br />work for which lhis pcrmil is issucd. My workers' compcnsotion insurancc canicr and ;nlicy numbcr uc: <br />Policy <br />_l ccrtify that in lhc pcrfornrance of lhc work for which lhis pcrmil is issucd. I shall not cmploy any person in any manncr <br />so 0s lo bccome subjsl to lhc workers' compcnsalion luws of California. and &Brcc that if I should hccom subjcct to thc <br />workcrs'comlrcnsarionprovisionsofSction]T00ofthctihorCodc.lshrll.fonhwithcomplywithlhosprevisions.. <br />WARNING: Failure lo scurc workers'smpensation covcrogc is unlawful. and shall suhjel !n cmployer to oiminal Jrcmlties and <br />civil fincs up lo onc hundrcd thousand dollars (Sl00.U)()). in addition lo lhc cosl of compcnsation, damges as provided for thc <br />Scclion 3076 ol Codc- intcrcsl <br />tqtVt,|$tn(? <br />LICENSI.]D CON'tRAC'TOR <br />DFCI,ARAl'ION <br />ol thc l]usincss illd Prolcs\ions Codc. ilnd my liccnsc is in Iull lirrcc and clli'ct. <br />Liccosc Nunrbcr: <br />Contractor: <br />W <br />I hcroby aflirm undcr rcnrlly ofpcrjury lhal lhcrc is a conslruclinr hndinS agcncy tbr thc lcrformancc ofthc work for which this lEnnil is <br />issucd (Scc. -1097. Civ. C. ). <br />[*ndcr's Name: <br />Lcndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcarhy {fliml undcr lcnalty of perjury onc of tlrc follo*ing dccluations: <br />l)cnxrlition Pcrmils-n shcst)s Nolillcaltrn Fcdcral Rcgulntions (Titlc.l0. Pda6) <br />-Rcquircd <br />Lcllcr of Nolificalion <br />_l certify thst the fcdcral rcSulations rcgarding asbcstos rcmoval m nor lpplicablc to this prejct. <br />lfilpmlfy tnur I hBrc rcad this applicalion 8nd state lhlr rhe abovc infomtion is corst. t agrc to comply with all City and County <br />tHinihKcs snd Srate bws rchting lo building constructio[ tud hcrcby authorizc rcIrEsentatives ofthis City ed Countyto ents upon tlE <br />abovc [rcntioncd propcrly for <br />Applicilill or AEcnt <br />Pcrmile narrc lprinl): <br />,^,", oglloll\ dt <br />Appliances <br />Metal 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 />Fina! Test <br />Meter Release ./ /I <br />FINAL ?/,t7 /zno -M)r> <br />Notes, Remarks,Etc./-vtl