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MECHANICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I haeby affim und6 paalty of psjury that I m cxmpt fiom the Contractors' License Law for the following r6on (S@.?031,5 <br />BBin6s ild Profcion Codc): Any City or County which requirs a permh to corutruct. alta, improve, dmolish or npair my <br />structue pdor to its isumcc, also require thc applicilt for such pemit to filc a sigtrcd $stmot that hc or $e b licosed pwat <br />lo thc prcvisioN of the Conlractor's Licensed law (Chapt6 9, Comencing with Setion 7000 of Divisioo 3 of the Busins ild <br />Prcfcssions Codc) or that he or shc is cxsnpt thqcfrom and thc bsis for thc allcgcd cxmpion. Any violatioo of Scction 703 1.5 by uy <br />applicant for a pcmil subjets the applicet to E civil pcnalty of not more lhm five hundrcd dollas ($500). <br />-1. <br />6 owner of the prope(y. or my employs with wages 6 their sole compmsation. will do the work dd thc struclwe is not <br />intoded or offscd for sle (Se.7044. Bsinss and hofsiom Code: Thc Conlraclor's Licme Larv dos not apply to m ou'ns of <br />thcprcperty whobuildsorimprcvsth6@n,edwhodo6suchworkhimselforhmclforthroughhisorhoomemploycs, <br />provided that such improvmots rc not intmdcd or offqed for sale. If, howfls. the building or imprcvmmt is sold within onc ya <br />ofcomplelion, thc Orvnq ttuilds will have the huden ofproring tha he or she did rct build or imp.ove the prctEly for the purpo*of <br />sle). <br />_1. m omer of thc propmy, m exclusivcly contraaing with licensed contractoE to costruct th€ projed (56. 7044. B6in6 <br />md PnrfssionCode:TheConlractor'sLiccnseLawdo6notapplytomownsofpropertywhobuildsorimprovesthssn. <br />md rvho contractsforsuchprojcctswithaContncto(s)licflscdpuNumttotheContractor'sLicemeLarv). <br />_l m exernpt under Sfrtion_. B. & P.C. for lhis reoon. <br />Df,te:_ _. _ Owner:_ <br />WORKERS'COMPENSATTON <br />PECLABAIJg! <br />I hereby affim undo ponlty ofpojury one ofthe following delaations: <br />-l <br />have md rvill mintain a Cenificalc of Coreqt to Self-lreure for workos' conrpensalion, d provided for by Sction -1700 of the <br />tabor Codc'1^o for lhe pofomance of the work for which the pmnit is isued. <br />will maintain lvotkets comperoalion insurance. c required by Sation 3T00 of the Labor Code, for the pofomilcc of <br />,which this pmnit is i$ued. My workqs' cotrrpensation imurmcc cuio md policy number uc:the work <br />Policy a -/ -ed <br />_l c€niry that in thc pdfomucc of the work for which this pemit is issucd" I shall noi mploy uy pqen h my menq <br />m c to become subjct to the wo*6' compcNation laws of Califomi& ed agrcc that if I stroutd becorne suUiet to ttrc <br />wo*m' compoation prcvisioN of Scclion 3700 of thc Labor Code, I slEll, funhwilh comply with thorc prcvisioG.. <br />WARNINC: Failure lo s6uc workm'compensation covoage is unlawful. md shall subjet il mploys to oiminal peiultis md <br />civil ftna up to onc hundrd thoused dollm ($100,000), in addition to the co$ of dmagcs a provided for thc <br />Sstion 3076 of lhe tibor Code, inttrBt ild anonEy's <br />o,r,,e -10'At <br />LICTNSED CONTRACTOR <br />TIECI,AIITI,TION <br />I hcby affm undo pcralty of psjury thal I m licanscd uda provision of Chaplq 9 (mmmcing with Sctio! 7000) of Division 3 <br />of the Buines ud Profsiore Codc, md my licruc is in full force md cffct. <br />{7Liccnse <br />O> <br />CONSTRUC'TION I FNITTNC ACENCY <br />I hffeby offrm unds penalty of pqjury thal lhqe is a corolruction lqding agency for the pofomauce of the work for which this pemit b <br />issued (Sa. .1097. Civ. C.). <br />Lender's Name. <br />Lender's Addrs: _ <br />I hmty affinn under penalty of pojury one ofthe following declaations: <br />Demolition Pmrits-Asbeslos Nolification Fedeal Rcgulations (Title 40, Pm6) <br />-Required <br />Lclltr of Nolifi cation <br />Z4l cqtiry that thc fedqal rcgulalioN regrdiog ubstos moval ue not applicablc to this prcj*t. <br />'/ t "otity rrral havc rad this applicEtion ad statc that thc abovc infomaion is corccl. I agre to @mply whh all City md Couty <br />ordimcB md Statc lrws rclating to buildirg construciio& ud hqcby authodze rcFsordiv6 of this City od Cowty to 6tq upotr tlE <br />abovc mmtioncd orcffiv for immimmse. q <br />appricmr oregmr si *^*", Al-( 4rr@ Ahr) aD ^", 3 -/ )' A O <br />Pmitenmc .-,/ b4-A) a Dt (/ das <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 />Rough 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 />Openinos <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release IA <br />FINAL 'r-\v,-7n Y'U.\o <br />Notes, Remarks, Etc.v\)