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I - <br />APPROVALS DATE I-CO MMENTS Owner-Builder Dec:laration . ' I hereby affirm under penalty of perj ury that I am exempt form the Contractors' License Law for the following reason (sec. 70.!.l .5 Busint'°.>~ <br />MECHANICAL INSPECTOR RECO RD <br />Appliances • and Pro fess ion Code): Any City or Count y which requires a pennit to construct. alter. im prove. demolish or re9air any strui.:lure. prior to its <br />iss uance. also requ ires the applicant for such permit to file a signed statement tha t he or she is licensed pu rsuant tO the !,rov;:;ions of the <br />Meta l Fire Place Contr:ictor·s Licensed Law (Chapter 9, Commencing with Section 7000 o f Division 3 of the Business and Professions Code) or t hat he c. .. <br />she is exempt the refrom and the basis for the alleged exempt ion .Any violation of Sect ion 7031.5 by any applicant for a pen nit subj ects th e <br />Evap Coo le r applicant 10 a civil pena lty or not mo re than fi ve hundred dollars ($500). I> <br />Furna ce I. as owner of the property. o r m y employees with wages as their so le compensation. will d o the work and the structure is not intended • <br />~ffered for sale ( See.7044. Business and Profess ions Code: The Contractor·s License Law does not a p ply to an owner of the propert)- <br />Co mpressor who builds or imp roves thereon. and who docs such work himself or herself or through his or her own employees. provid ed tha t such <br />improvements are not intended or o ffered for sale. If. howe"er. the building or improvement is sold w ithi n one year of compl~~ion. the <br />Mi sc. Equi p me nt Owner-Builder will have th e burden of proving that he or she not build or impro\fe fo r 1he purpose of sale). <br />I I'(~· as owner of th e property. a m exclusively contracting w ith lic ensed contractors to construct the project ( Sec. 7044. Busini:ss and <br />ro ession Co de: The Contractor's Licens e Law does not ap ply to an owner o f property who builds o r improves thereon . and w ho <br />Duct Work contracts for such projects with a Contrnctor(s) licensed pursuan t to the Contractor's Lice nse Law.). <br />Pre -Ins ul atio n _I am exempt under Section .B. & P.C. for this reason. ~ <br />Date II_ () :__ Jo I 6 <Avner: c;:/ac/4;5 ;ii CC. , ~ In sul ati o n <br />Smoke Detectors Insta ll ed WORKERS COMPENSATION DEC LARATION-- <br />I hereby affirm under penalty of pe rj ury one of the fo llowin~ dec larat ions: <br />Ro ugh Du ctwo rk _I have and w ill mainta in a Certificate of Consent to Sclr-l nsu re fo r workers' compe nsation. as pro vided for by Sectio n 3700 or the <br />Labor Cod e. for the per formance of the work for which the permit is issued . <br />_I have and w ill mainta in workers' compensa tio n insurance, as required by Sect ion 3700 of the Labor Code, for t he performance of the <br />work for wh ich this permit is issued. My workers· compensation insurance carrier a nd po licy number are: <br />Vents Carrier: <br />To il et R oo m I Clothes Drye r Policy Number : Exp ires: <br />Res identi a l Ra n ge (This section need no t be completed if the pcn nit is for One hundred dollars iSIOO I or less) <br />Oth er ~Ml certify that in the perforlllance of the work for which this pcnnit is iss ued. I shall not employ any person in any manner so as 10 <br />be ame subject to th e workers' co mpensation laws of Californ ia. and agree that if I should become subject to t he workers' <br />compensat ion provis ions of Section 3700 of th e Labor Code, I shall. forthwilh comply wil h 1hose provisions .. <br />Hood Date: I/_ 0 ~-,J-6) {,, Applicant: C: -,,,ik¾ <br />T y pe I Hood WARNING: Failure to secure workers' compensation coverage is un lawful, and shall subject an employer to crim ina l pena lties and civil <br />lin es u p to one hundred thousand d ollars ($100.000).in addition to the cost o f compensation. damages ns provided for the Section 3076 o f <br />T ype II Hood the Labor Code. interest and attorncy·s fees <br />Grease Du ct LICENSED CO NTRACTORS D EC L AR AT ION <br />I hereby affirm under penally o f perjury tha t lam licensed under provis ion of Chapter 9 {commencing with Section 7000) of Division 3 of <br />the Business and Professions Code. and my l icense is in full force and effect. <br />Fire Damper License Class: Lice nse Number <br />Op e nings Drtte: Contractor: <br />In stallati o n C O NST RUC TION L ENDING AGE NCY <br />I hereby affirm under pe na lty of perjury that there is a construction lending agency for the pcrfonnance of the work for which this pennit is <br />F .D. Drop Test issued (Sec. 3097. C iv. C.). <br />Lender's Name: <br />Lender's Address: <br />Above Hard Lid A PPLICANT'S DECLA RATIO N <br />Above T-Ba r Demolition Pe rmits-Asbestos Notificat ion Federal Regulations (Title 40. Pait 6 ) <br />_ Required Letter of Notific atio n <br />Ii/ ' _I cert ify that the federal regulat ions reg a rd ing asbestos removal are not applicable to this project. <br />Rough Mech. t v/1--u/ It I '1/)Rrl 1/ J ~ Jli1 certify that I have read this applicatio n and state that the abo,,e information is correct. I agree to comply with all City a nd Coun ty /l ~ <br />Fina l Test I I I / I ,-..:..:. 1.../ ordinances and State Laws rela ting to building construction, and here by author ize rcprcscntalivcs o f this City and County to enter upon the <br />above ment io ned property for insp4 u'l)oses., <br />Mete r Release . 1 I , A pplicant or agent sig.: <:::;'. ~ Date : //_ 0~-1 t. <br />FINAL 1t1 IL q /J v/ ;;;. ',,({£_/ Jc// Permitt ee name (print}: G'hJT ~<f'-4 he '2-- <br />M:\W P51\Perm1t-lnspect1on Forms\Mechanical-lnspector Record.doc 03.31.06