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MECHANICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG. COMMENTS Owncr•Buildcr Declarat ion . ( hereby nffirm under pe na lly of perjury that I am exempl form the Contractors' License Law for the fo llowing reason (~ec.703 1.5 Business Appl i ances and Profession Code): Any City or Count y which requires a permi1 to cons truct alter. improve. demolish or repair any ~•~·w .. ;ure, pn• r tn its issuance. also req uires the applicant for such permit to fi le a s ign ed statement that he o r she is licensed pursuant to the provis ions o,"!ht: Meta l Fi re Place Contractor's L icensed Law (Cha pter 9. Commencing w ith Section 7000 of Divis io n 3 of th e Business a nd Professions Code} o r 1h::i t •he or she is exempt therefrom and the basis for the a lleged cxemp1io11 .Any violation of Section 7031 .5 by any applicant for a pcnnit subject!.· the Evap Cooler applic ant to a c ivil penalty of no t m o re than five hund red dollars {$500). Furna ce ~ as owner of the property. or my employees with wages as the ir sole compensation. will d o the work and the structure is 001 intended or offered fo r sa le ( Sec. 7044. Bl1siness a nd Professions Code : The Contractor 's License Law d oes not apply to an owner of the property Compresso r who builds or improves the reon. and who docs s uch work himself or herself o r through h is or he r own e mployees. provided that such improvements are not intended or offered for sale. If. however. the build ing or improve ment is sold with in o ne year o f com plet ion. th e Misc. Equipm ent Owner-Builder will have the burden o f pl'oving that he o r she not b u ild or improve for the p urpose o f sale). _I. as owner of t he property. am exclusively contracting with li censed contmctors to construct the project ( Sec. 7044 . Business and Professio n Code: The Contractor"s License Law does not apply to an owner of property who builds o r im p roves !hereon . a nd who Duct Work contracts for such proj ects w it h a Contractor(s) licensed pursuant to the Contractor's License Law.). Pre -In s ula ti on _I mn exempt under Secti o n .B .&P C.~ l ... -!-\(.:, Date: . In s ulati o n Owner:)(._ S m oke D etectors In stalle d WORKERS C OMPENSATION D ECLARAT I ON I hereby affirm under penalty o f perjury o ne o f the fo llowing declarat ions: Ro ugh Ductwo rk I hav e and will mainta in a Cert ificate of Consent 10 Self-I nsure for workers· compensation, as pro vided for by Sectio n 3700 of the L1bor Code. for the performance oft he work for which the permit is iss ued. _I have and will ma intain workers· compensation in surance. as required by Secl ion 3700 oft he Labor Code. for the performance o fthc work for wh ich this pern1it is issued. M y workers· compensat io n insura nce carr ier and policy number are: Vents ,I Carrier: T o il e t Room I Cl oth es Dryer lp/ tf 171 ~ Pol icy Number : Expires: Res identi a l Range -(This section need not be completed if the permit is for One hundred d ollars {$100; or less) Oth er -r:/J certify tha: in the perfonnance o f the work for which this pe rmit is issftd. I shall not em ploy any person in any manner so as to became su bject to the workers · com pensa tion laws ofCaliforma. and agre t al ifl s hould beccme subject to the worke rs· -compensa1 ir.n previsions o f Section 3700 of the Labor Cnde. I shall.1J comply w ith those provisions .. ·---- Date:• \"")---! -lb Applicant : 'K 'J A----Hood - Type I Hoo d WARNI NG: Failure to secure workers' compensation c overage is unlawful. a nd shall subject an employer to criminal penalties and civ il lines up 10 one h undred tho usand dolla rs {$100.000).in additio n 10 the cost of compensation. damages as provided for the Section 3076 of Type II Hood the Labor Code. interest and attorney"s foes. Grease Du ct Ll!:;ENSED C ONT RACTORS DE CLARATIO N I hereby affin11 u n der pena lty of perjury that I am licensed under provisio n of Chapter 9 (commencing w i1h Seclion 7000 ) of Divisio n 3 of the Business and Prorcssions Co de. and my license is in full fo rce an d effect. Fire Damper License C lass: L icense Number O peni ngs Date: Contractor: In sta llati o n CONSTRUCTION LENDING AGENCY 1 hereby affirm under penalty o f perjury that !here is a construction lending agency for th e perfonnance o f the work for which this perm it is F .D. Drop Test issued (Sec. 3097. Civ. CJ. Lender"s Name: Lende r·s Address: Above Hard Lid APPLICANT'S DECLARATION Above T-Bar Demolition Permits-Asbestos Notification Federal Rcgtlialions (Tit le 4 0 . Pan 6) _ Required Letter of Notification I I _I certify that the federa l regula tions regarding asbes1os removal are nol applicable lo this project. Rough Mech. <,?/I 'J )11 ;{).a 5 (i 9,1 ➔ -d, ,~; ,, "" , •• '"" ,.;, oe•:~ ""' '"" "" ••• "'"""'"" ;, oo-, , '""' ,o ""''' ,.;," '" c;., •• ~,m, Fi nal Test ordinances a nd S tate Laws re la ting to build. 1g pnstruction. and he re by a uthorize representatives of this City and County to enter upon the above m ent io n ed property for inspection r-j- Meter Release .,,,..., Ap plicant or agent sig.: ~ ~ Date: • l t.--( -( C,. FINAL l!i~I ~!'6 t ~~;;z.r; Pennittee name (print): l(.._ :!wtt v~ M:\WP51 \Perm,t-lnspect,on Forms\Mechan,cal-lnspector Record.doc 03.31.06