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MECHAN!CAL.INSPECTOR RECORD <br />APPROVALS DATE ID/S!G.COMMENTS OWNER BUILDER DELCARATION <br />I hoeby affim unds pcnalty of pcrjury that I m cxempt from the Contractors' License Larv for thc following rwn (Scc.7031.5 <br />Busincs ad Profeion Codc): Any City or County which rcquira a pornit lo coNtruct. alt6. improvc. dcgelish or rqair my <br />structuc. Fior to its iswcq also requta rhe applicmt for such pmit to filc a signcd slalmot thal hc or shc b licosed plmmt <br />to thc provisioE of thc Cont actor's Licensed Law (Chaptq 9, Commencing with Sction 7000 of Division 3 of the Busins md <br />Profsions Code) or thst ho or she is cxmpt thqcfrom ed thc basis for thc allcgcd cxmpion. Any violdion of Sdion 7011.5 by any <br />applicst for a pcmit subjcts thc applicml to E civil poalty of not morc the five hundrcd dollus ($500). <br />_1. s owna of thc propcrty, or my employG with wag6 6 thcir solc composalion. rvill do thc work md the structue is not <br />intoded or offsed for slc (Se.7044, Buines md hofcssio$ Code: The Contrsctor's Licflse Law does not apply to m owns of <br />the prcpsty who huilds or improvs thq@tr od who do6 such rcrk hirnsclf or hmlf or through his or ho own cmployce, <br />provided that such improvmts rc not intqded or offsed for sle. If. howws, the tuilding or improvmqt is rcld within one )q <br />of complaion the Orvnd Buildq will have the hr&r of proving that he or shc did rct build or imp&c thc popaty for the purpor of <br />slc). <br />_1. u omaof thc propqiy, m exclsively contracling with licosed contracloB to construcl the prcj(t (Se. 7044, Bsins <br />and ProfesiooCode:TheContractor'sLiccnscLawdo6nolapplytomown6ofprop€rtywhobuildsorimprovslhs@n, <br />and who contracts for such projsls with a Contmcto(s) licmsed pu6@t to thc Conlractor's Licmse Law). <br />-l <br />m exempt undq Sction-. B. & P.C- for this r6on. <br />Date:_ Owtrer:_ <br />WORKERS' COI\IPENSA'TION <br />DECLARA'TION <br />I hscby a,Iirm unds pcnalty ofpojury one ofthc [ollowing dclilationsi <br />_l have md will nraintain a Ce(ificate of Co6ml lo Self-lnsure for rvorkers' conrpensalion, as provided for by Sction 3700 of the <br />I-abor Code, for th€ pq fonnancc of the u.ork for which thc pmit is issued. <br />_l have and rvi I I maintain workers' compensation insurance. o requiled by Sccl ion .3700 of the Latrcr Code. for the pofomocc of <br />the work for s'hich this pnnit is issuei. My workers compmsalion insurance cmio ud policy numbo ae: <br />Policv Number: Exoircs: <br />_l certiry that in the prfonnance of the work for which this psmit is bsued. I shall not qnploy any poson in any moner <br />so 6 to become subject to thc workm' mmpmation laws of Califomia. ed agrfr that if I should become subj$t to the <br />workqs' compmation provisioro of Setion 3700 of lhe Labor Code. I shall. fonhwith comply with thoe provisioB.. <br />WARNING: Failuc to sue rvorkm'comperuation cov@ge is unlawful. ud shall subjfft a mployr to qiminal pquhie od <br />civil fina up to onc hundrcd thoMd dollm ($100,000), in addition to thc cost of compwtion, damge re providcd for thc <br />Sqtion 3076 of thc Lsbor Code. intEqt od attomey's fc.) <br />LT(]i]NSED CONTRACTOR <br />DECLARATION <br />I hoeby affm unda pmalty of pcdury thar I an licosel unda provision of Chapts 9 (commcing silh Scction 7000) of Division -1 <br />of the Busins md Prefe$ions Code. ed my lica* is in full force md effet. <br />LimcClas: LimcNmb6;- <br />l)trlc: <br />CONSTRUCTION I TNnlNC ACT'NCY <br />I hrcby allim uda pcnalty of pqjury thd thqc is I construction letrding agocy for thc pofoIrmcc of lhc wort for *tich this pqmil b <br />issucd (S*. 3097, Civ. C.). <br />Lcndq's Name. <br />l.ender's Addr6s: <br />APII.ICANI.DECI.ABAIION <br />I hqrb affrrr uodo poalty of pqjury onc of the following deluatiow: <br />Dmolition Pmirs-Asb€tos Notificatiotr Fcd68l RcgulatioN (Titlc 40. Pan6) <br />-Requircd <br />trttq of Notificatiotr <br />-l <br />cdiry that the fedoal rcgulatioro regrding obclos rmovalae not spplicable to this prcj(t. <br />-l <br />cdiry that I havc rcad this application ed statc that thc above infomation is corecl. I agr€ to comply wilh all Cityud County <br />ordinancG md Statc Lsws relating to building coNtruction. ed hqeby authorize rcpremtativG of rhis City @d Couty to mt6 upon thc <br />abovc motioned property for irupEtioo plrpose, <br />Applicmt or Agmt Signaturc: _ <br />Pmitcnme <br />Appliaryiss' - <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 Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openinos <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rouqh Mech. <br />Final Test <br />Meter Release <br />FINAL <br />Notes, Remarks, Etc.