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APPROVALS DATE ID/SIG. Appliances Metal Fire Place Evap Cooler Furnace Compressor Mi sc. 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 Above T-Bar Rough Mech. Final Test Meter Release ' FINAL M:\WP51\Perm,t-lnspect,on Forms\Mechanical-lnspector Record .doc 03.31 .06 MECHANICAL-INSPECTOR RECORD COMMENTS Owner•Builder Declaration • I hereby affirm under penalty of perjury that I am exempt form the Contractors' License Law for the fo ll owing reason (sec.703 1.5 .. Uusiness and Profession Code): Any City or County w h ich requires a pen nit to construct. alter. improve. demolish or repair any structure. prior to its issuance. also requires the applicant for such permit to fil e a signed statement that he or she is licensed p ursuant to th e provision~.....-.·t he Contractor·s Licensed Law (Chapter 9, Commencing with Section 7000 of Division 3 o f the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged e xemption ,Any violation of Section 70315 by nny applicant fo r a pem1it subjects the applicant to a civil pe nalty o f not more than five hundred dollnrs {$500). ' _I. as owner o f the propeny. or my employees with wages as their sole c mpensation. will do the work and the structure is not intended o r ofTered for sale ( Sec.7044. Business and Professions Code: The Colllrac or's License Law does not apply to an owner of the propeny who builds or improves thereon. and who does such work himself or hersc or through his or her own employees. provided that such improvements nre not intended or offered for sale. If, h owever. the build ing or im provement is sold within one year of completion. the Owner-Builder will have the burden ofprovmg that he or she not build or i1 1prove fo1 the purpose ofsnlc) _I. as ownerofthe prope11y, am exclusively contractmg with hcen.sed co~t ctors to construct the proJect ( Sec 7044. Business and Profession Code T he Contractor's License Law does not apply to nn owner o 1operty who builds o r improves thereon, nnd who contracts for such proJects with a Contractor(s) licensed u r ant to the Contra tor's License Law ) Dat::m;;J~i:7on JM\ .&P.C for th,s reaso ~ ------ / f . / woR~t}~s-~o~ITTNSA noN DEC LARATION I hereby affirm under penalty of perjury one of the following decla ra tions: _I have and will maintain a Certificate or Consent to Selr-Insure fo r workers· com pensat ion, as provided for by Sect ion 370 0 of t he Labor Code. for the performance of the work for which the permit is issued. _I have and will mainta in workers· compensation insurnnce, as required b Section 3700 of the Labor Code, for the performance o f the work for which this per mit is issued. My workers· compensation insurance c rrier and policy number are: Carrier: _____________________ +------ Policy Number: __________________ -'f--E xpircs: __________ _ (This section need n ot be completed if the permit is for One hundred dollars { 100} or less) I ccnify that in the performance of the wo rk for which th is crmit is issue ( I shall not employ any person in any manner so as to became subj ect to the workers• compensation !11ws of alifo ia, and agree lrlat if I should become subject 10 the workers' compcn/'i~n p'Jvis~or of Section 3700 o f the Labor d I shall. fm1hwitl comply w i1h those provisions .. Date: /1-/ { q//c Applic t :_...._ ____ ~_-~O;Jt,~------------- WARN I NG:4ailL to secure workers· com pensation covera~ is unlawful. and shall subject an employer to criminal penalties and civi l fines up to one hundred thousand dollars ($100.000).in addition to the cost of compensat ion. damages as provided for !he Sec1ion 3076 of the Labor Code. interest and attorney"s fees . LICENSED CONTRACTORS DEC LARATION I hereby affirm under penally of perjury 1hat I am licensed under provision of Chapter 9 (commencing w ith Section 7000) o f Div isio n 3 o f the Business a nd Professions Code. a nd my license is in full force and effect. License Class: ______________ License Number _______________ _ Date: _____________ Contractor: ____________________ _ CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a constniction lending agency for the perfonnance of th e work fo r which 1h is pe rmit is issued (Sec. 3097. Civ. C.). Le nder 's Name: _________________________ _ Lender's Address: ----------t--------------- APPLICANT'S DE C LARATION Demolition Permits-Asbestos Notification Fede a l Regulations (Title 40. Part 6) _ Required Letter o f Notification _I certify that the federal regulations regarding sbestos removal are not apphcable to this proJect _ I cert ify that l hav~read 1i s appl al ion and st e that 1he above mformat1on 1s concct I agree to comply with all City and County ordmances and Slate La latmg to bmldmg cons uct1on. and he1eby autho112e represenlallves of this C ity and County to e nter upo n the above menltoned prope o ns pcclton purposes _ Ll Applicant or agent s1g ~----~ Date. t'2-lfil (, Pcrmitteenamc(print): __________________________________ _