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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE !D/S!G.COMMENTS oWNF]R BUII,I'T]R DI:I,CARA'IION <br />I hcrchy ill'firnr undcr pcnrlly ofpcrjury that I am cxcnrpt lionr thc (i)nlracktrs' Liccnsc Law li)r lhc Ii)lk)wing rcilson (Scc.7031.5 <br />llu\inc'ss rM Prolcssiur (ixlc)r Any City (,r (:ouilly shich rcquircs a pcrnril lo con\ltucl. ahcr. impr{rvc. dcnt)li\h or rcpnir {Dy <br />stntcturc. pri()r to it\ is\uancc. also rcquircs thc xpplicilnt for such Jtrilril lo lilc a signcd \lrlcnrcnl lhil hc rrr shc is liccnscd pursurnl <br />lo thc provisions ol'lhc Coiltraclor'\ Liccnsctl Law (Chaplcr 9. Conuncncing wilh Scclion 7U)O of Divisir)tr 3 (,[ lhc Busincss ald <br />rpflicilntlirrapcrtrritsubjcclslhc apflicanlklrcivilpcnaltyoliloliltr)rclhanfivchundrcddollars(S5(X)1. <br />_1. as owrcr of thc prcpcny. or my cmplo)cs with wagcs as thcir slc comlrcnsalion. will do thc wott ard the snEtw is ml <br />intcnd€d oroffcrcdforsle(Se.?044.BusinessandProfcssionsCodc:ThcContractor'sLiccnkLxwdoesnotspplytoanowrcrof <br />thc prclrcrty who builds or impmres themn, md who dfts such work himsclf or hersclf or through his or hcr own employees. <br />provided thst such imprcwmnts rc rct intendci o offcrcd for gh. lf. howew. lhc tiliHing or ir{rrcrcEnt is mH within orc ltr <br />of @nphtion, thc Owner BuiHs will havc the budm of prcvin8 that he or she did ml buiH or itrq,revc thc pnlf,rty for thc purynrc of <br />slc). <br />_1. as owncr of thc prcpcny. am exclusivcly contractirg wilh liccnsed contructos to construcl the projctt (Scc. 7044, Business <br />ard PrcfssionCode:TheContrsctor'sLicenscLawdocsnotapplytoanowncrofpropcrtywhobuildsorimproveslhereon, <br />snd who @nlncls for such prcjcts with I Conmclo(s) liccn*d pursuani to lhc Conlraclor's Liccnse kw). <br />I am cxcnrnt unJcr Scctir)n-. B. & P.C. for lhis rcason. <br />l)illr ()litrcr <br />WORKERS' COMPT'NSATTON <br />DECLARATION <br />I hcrcby ulfirm undcr pcn{ll y of pcrjury onc of thc folhwing dcchralions: <br />_lhavcamlwill nuintainaCc(illcatcofConsnttoSclf-lnsurcfor*orkcrs'contlxnsnlk)n.as prolidcdtorbySeclknr3?00oflhc <br />Luhor Codc. tor thr' pcrforiluncc o f thc sork lor which lhc pcrmil is issucd./ <br />\.havc anrJ will nHintain workcrs compcnsation insutuncc. as rcquircd by Scclion J?U) otthc tibor Codc. for lhc pcrformmc of <br />thc work for which this pcrmil is issucd. My workcrs'compcnsalion insurance cilricr and Jnlicy numbcr uc: <br />Policy <br />_l ceflify that in lhc performnce o[thc work for which (his pcrmit is issued. I shall not employ nny pcrson in any manmr <br />s as lo hccom subjcct to thc workcF' @mpensstion laws of Califomia. and agrcc thd if I should bccore subjcct to thc <br />workers' comlEnsation pmvisions of Scction 3700 of the tntnr Codc. I shdll. fonhwith comply with thos provisions.. <br />WARNING: Failurc to sre workcrs'comFEnsation mvcmgc is unlawful. and shall subjet m cmJ,loycr to qiminrl pemltbs and <br />civil fines up to om hundrcd thousnd dollrxs ($100.000). in addition to thc cost of compcnsalion. damges as provided for thc <br />Section 3076 of thc Libor Codc. inlcresl and altorey's fccs. <br />LICFNSED CON'T'RACTOR <br />DICI4IBAII0N <br />I hcrcby allirm undcr pcnalty of pcrjury thal I an liccnscd undcr provision ofChnplcr 9 (connrrcncinS wilh Scclion 7(il)) of Division 3 <br />ol thc lJuriocss and Pmfcssions Codc. and nry liceil\c is in lull lorcc ild ctfcct. <br />1 0LiccnscNunrxLr: <br />CONS'I'RT]C'tIoN LIJNl)INC ACT.JNCI' <br />I hcrcby tlfirm undcr lEnalty ol pcrjury that thcrc is s con$lruction lcnding ogcncy li)r lhe pcrfoilMncc of lhc pork lirr which this prnrit is <br />issucd {Scc. 3097. Civ. C.). <br />l-cndcr's Nurnc: <br />bndcr's Addrcss: <br />APPLTCANT ITECLARATION <br />I lrrchy rllirD undcr |x[!lly of pcrjury onc ol lhc folk)wing declilrations: <br />Dctrnliti()il Pcrmits-A\bcslos Nolilicalion Fcdcral Rcgulrtions ('l-illc 40. l'an6) <br />-Rcquircd <br />lxllcr of N(nilicali(nr <br />-l <br />cerlily that lhc fcderalrcgulations rcguding astEslos rcn$vtrlare not applicublc to this Projcct. <br />is cor(t. I agre lo comply with all City and Counly <br />atnvc mnlioncd pmlEny <br />Applicanl or Agcnt <br />Permitee nilm <br />lo <br />nill slalc lhill lhc <br />aulhoria reprcscnlutivcs ofthis City and lo utEn thc <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 />Tvpe 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 />n <br />Rouqh Mech.,nWh) <br />FinalTest <br />Meter Release ln <br />FINAL 1/h/z | .-z zu r'-cn <br />Notes,Remarks,{C -(-"I .il/ <br />//<tt t <br />I)sle:-- <br />- <br />Apdiotrt:-- <br />Dste:_