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M ECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE !D/SIG.COMMENTS Ownfi - Buildfi Dcclaralion <br />I hereby aflirm under pemlty of perjury that I 8m exempt form the Contradors' License law for the following reson (s4.70] 1.5 Bsincss <br />snd Profcssion Code): Any City or County which rcquircs a pcmit to coNtruct. altcr, improvc, dcmolish or rcpair my struclue. prior to its <br />issuancc. &lso rcquirB thc applicsnt for such pcrmit to filc a Bigncd statcmcnt thst hc or shc is licc$cd punuant to thc pmvisioN ofthc <br />Contracto. s Lrcensed Law (Chapter I, Commencing with Setion 7000 ofDivision 3 oflhe Busin6s aod Prof6siom Codc) or that hc or <br />shc is cxcmpl thseftom and thc bsis for thc allcgcd cxcmptiotr .Any violation ofsetion 7031.5 by any rppticant for a pmnil subjects thc <br />applicanl to I civil penslty ofoot morc than livc hundrcd dollm ($500). <br />_1. 6 owncr of lhe propqny. or my cmployccs with wag6 as thcir solc compcNation. will do thc work and thc strucluc is nol intmdcd <br />o, offered for $le ( S*.7044, BusinBs and Ptofcssions Codcr Thc Conlrsctor's Lic€BG Lsw do6 not.pply to an owner oflhe pmpcrty <br />who builds or improv6 lhdcon. and who doo such work himsclf or hffilf or Ihrough his or hr owD cmployG. providcd rhat such <br />improvcmcnls arc not intcDdcd or offqcd for salc. lf. how.v6, thc building or improvcmcnt i! sold within otrc ycu ofcomplction. thc <br />Owncr-Buildd will havc thc burdcn ofproving lhat hc or shc not build or improvc for th€ purposc ofsalc). <br />_1. 6 owncr of lhc propcny. am cxclusivcly contracting with liccmcd contraclon to coNtrud thc proj€i ( 56. 7M4. BBin6s ud <br />Profe$ionCodc TheContrador'sLicc6€Lawdo6nolapplytosnownqofpropcatywhobuildsorimprovBthcrcon,mdwho <br />contr.cts for such projds with a Contr.ctor(s) licenscd pursunt to the Contrador's License kw.). <br />.-_l am ercrnpt undcr Section <br />Dalc: <br />& P.C. for this rcuon. <br />Ou'ncr: <br />}VORKERS COIIIPENSATION DECLARAl'ION <br />I hcreby amrm under penalty ofperjury one oflhe following declarations: <br />_l havc ud will mintain a Ccnificatc of Co6cnt to SclfJEure for rcrkers' compeNtion, as provided for by Sstion lToo of the <br />labor Codc. for thc perfomncc of thc work for which thc pcmit is issucd. <br />_l have and wtll maintarn workers compensation insurance. as required by Section 3700 ofthe Labor Code, for the perforronce ofthc <br />work for which this permit is issued. My workers' compensation insurance etricr and policy numbcr trc: <br />poticyNunbqt NTg 6-?q74L7S)T'lLlCl rxpircs: I- /- If <br />(This scction nccd not bc complcted if thc pmit is for Onc hundrcd dollsn {$100} or less) <br />_t ccaify that in the pcrfomancc of the work for which lhis pcmit is issucd. I shall not mploy any p6on itr any manncr so s to <br />bccamc subjst to lh€ workcrs' ampenstion laws ofCalifornia, and agre that ifl should become subjst to the workets' <br />with those provisions.. <br />d/rg" ,t unto*tu|and shall subjct an employer to qiminal pculrics and civil <br />aililition to the cost ofcompensrtion. damages 6 providcd for thc Scction 3076 of <br />WARNING Failure to secure workers' compensation <br />fincs up to onc hund.ed thousmd dollars ($100.000).in <br />lhe tabor Code. inlerest and attorney's fees <br />LICENSED CONTRACTORS DECLARATION <br />I hccby aflim undr pcmhy ofpcrjury that I m liccnscd unda provision ofchsptcr 9 (commcncing with S(tion 7000) ofDivision 3 of <br />the Buincss and Profcsioro Codc, md my liccmc is in full forcc aod cffcct. <br />l.icense ti""*rNu *, ZQ5fiQ <br />D'* 6'27'/c/ contncto. 'TiLlS,A) - (alL COrlrS1lc+tLlDPt <br />th@byafrmuod6pcultyofpgjurythat**ffifficcofthcwortfoIwhichthispmitis <br />irsucd (Sc. 3097. Civ. C.). <br />lrndo's Namc: <br />l.ender's Address <br />APPLICANT'S DECLARATION <br />Dcmolition Pcmils-Asbcstos Notification F.dcral Rcgulstions (Titlc 40. P8n 6) <br />_ Requbcd ktts ofNotification <br />_l ccrtify thst lhc fcdcral rcgulatiom rcgdding 6b6tos rcmoval ec not spplicablc to thfu projcct. <br />- <br />I ccdiry thst I have rodthis application md ststc thrl thc abovc infomrtion is cotrcct. I agre to comply with all Chy and Couty <br />ordimncB and Shtc laws rclating to building coctruction, md h6eby authorie rcprGatstivcs of this City md Couty to mto upon thc <br />abovc mentioncd prope(y for, <br />Applicant or agcnl si8.: <br />I'cnnittee namc <br />6-zz- <br />Appliances <br />Metal Fire Place <br />Evap Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar f ^^ r t ,,1 JIA <br />/ ,lll '/L,rRough Mech.F)-n rra t.t*A <br />Final Test I I Nt t t' lvl <br />Meter Release /- <br />FINAL llsqu <br />,*rr,, Trzt$ttillEllS <br />Dnc. 6-2?-lr.l <br />^opn6t: