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APPROVALS DATE ID/SIG. Appliances Metal Fire Place Evap Cooler Furnace Compressor Misc. Equipment Duct Work Pre-Insulation Insulation Smoke Detectors Installed Rough Ductwork Vents Toilet Room I Clothes Dryer Residential Range Other Hood Type I Hood Type II Hood Grease Duct Fire Damper Openings Installation F.D. Drop Test Above Hard Lid 11 I Above T-Bar Rough Mech. Final Test Meter Release I FINAL M:\WP51\Perm,t-lnspecuon Forms\Mechamcal-lnspector Record.doc 03.31 .06 MECHANICAL-INSPECTOR RECORD • COMMENTS Owner•Builder Declaration I hereby affirm under penalty of perj ury that I am exempt form the Contrnctors· Lice nse Law fo r the following reason (sec. 70 31.5 Business and Profession Code): Any City or County which requires a permit 10 construct. alter. improve. demolis h or repair any structure. prior to its issuance , also requires the applicant for s uch permit to file a signed statement that he or she is licensed pursuant to the provisiG.AS of the Contractor's Licensed Law (Chapt er 9, Commencing with Section 7000 of Divis io n 3 o f the Business a nd Professions Code) o r 1hn (hc or s he is exempt therefrom and the basis for the a ll eged exe mption .Any violation of Section 703 1.5 by any applicant for a pennit subjects the applicant to a civil pe nalty of no l more than five hundred d oll ars ($500). ' _I, as owner of the property. or my employees with wages as their sole com pensation, w ill d o the work and the structure is not intended or offered for sale ( Sec. 7044, Business and Professions Code: The Contractor 's License La w d oes not apply 10 an owner of the property who builds or improves th ereon , and who does such work himself or h erself or through h is or her own employees. provided "-Ii.al such improvements are not intended o r offered for sale. If. however. the building or im provement is sold within one year of~ompletion. the Ow ner-Builder will have the burden of prov ing that he or she not build o r improve fo r 1hc purpose of sale). _I. as owner o f the property, am exclusively contracting with licensed contractors to construct the project ( Sec. 7044., Busin ess and Profession Code: The Con tra ctor's L icense Law d oes not apply to an owner of property who builds o r improves thereon,., and w ho contracts for s uch projects with a Contractor(s) licensed pursuant to the Contrnctor·s License Law.). _I am exempt under Section ________ .. B. & P.C. for this reason. Date: _____________ Owner: _________________ _ WORKERS COMPENSATION DECLARATION I hereby affirm under penalty of perj ury one of the fo llowing dcclnrnt ions: _I have and will maintain a Certificate o f Consent to Self-Insure for worke rs' compensation, as provided for by Section 3700 of t he Labor Code. for the perfonnance of the work for whi ch the pcnnit is issued. _I have and will mainmin workers· compensat ion insurance. as required by Section 3700 of the Labor Code. fo r the performa nce of1hc =~~or,~;/:;;m~rti~;•? comp~~::•::;•;:po licy ;;~ p Poli cyNum:erC. $ ,r5QO"';:f-1/ 8 Exp ir~s: -0 3-//64 k (This section need not be compl ete d if th e pennit is for One hundred dollars {$100) or less)' _I certify that in the perfonnance of the work for which this pennit is issued. I shall not employ any person in any manner so as to became subject to the workers· compensation laws of California, 1 ~;:t 1 grc c tlm if l should become s ubject to the workers· compensation provisions of Section 3700 of the Labor Code, I sha~l/, rthwith comply wi1h those provisions .. Date: J)#IJ-/(-Jf, AppliY.¥,-, ·=-fl.''J=11 :::::' ~,::__ ______ _ -r I 11 WARNING: Failure to secure workers ' compensa tion coverage is unlawful. and shall subj ect an employer to crim ina l penalt ies and civil fines up to one hundred thousand d oll ars ($100.0()0).in addition to the cost of compensation. damages as provided fo r the Scct"ion 3076 o r the Labor Code, interest and attorney"s recs. LICENSED CONTRACTORS DECLARATION I hereby affmn under penalty of perj ury thnt I nm licensed u nd er provision of Chapter 9 (comm encing w ith Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force nnd e ffect. - License Class:_•_-'ff>"=.;,---------License Number 7 $, ;/-!3 5 L Date: AJ{JV -if:-/ b ContraJ 7 • J /J r{J..e_, //2i_ck ( ~ '.X-J~ CONSTRUCTION LENDING AGENCY I hereby aITinn under penalty of perjury that there is a construction lending agency for the performance of the work for which this pennit is iss ued (Sec. 3097. Civ. C.). Le nder's Name: _________________________ _ Lender's Address: _______________________ _ APPL ICANT'S DECL A RATION Demolit ion Permits-Asbestos Notification Federal Regulations (Title 40. Part 6) _ Required Lcttcro fNotifica1 ion _I ccrtiry that the fed ernl regulations regarding asbestos removal are not applicable to this project. _ I certify that I have read this application and stale that the above infonnation is correct. I agree to comply w ith all City a nd Count y ordinances and State L1ws ret·!~g to bu1 ldmg construction. and hereby authorize representatives ofthlS Cny a nd County to enter upon the :::~c:~n~~o:::n~~~/~,~~;c~o~~rp:ses 1 _ , -Da te. /llt/J,r/(-} 6 1;,, . I .Ii A l " ' Permitt ee name (printV:: • //J-,/1;. ./ (/) if ,//1 / -} /-.J'"'