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APPROVALS DATE ID/SIG. Appliances Metal Fire Place Evap Cooler Furnace Compressor Mis c. 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 Op e nin gs In stallation F.D. Drop Test Above Hard Lid Above T-Bar MECHANICAL-INSPECTOR RECORD COMMENTS Ow ner-Builder Declaration I hereby affirm under penalty of perjury that I a m exempt form the Contraclors' License Law for the fo llowing reason (sec.7031.5 Bus iness and Pro fession Code): Any C ity or County which requires a permit to construct, alter. improve, demolish o r repair any structure. prior to its issuance , also requires the applicant for such permit to file a signed s tatemenl that he o r she is licensed purs uant to the provisio ns of the Co ntractor's Licensed Law (Chapter 9. Commencing w ith Section 7000 of Division 3 of the Business and Professio ns Code) or th:u he or she is exempt lherefrom and t he basis for the alleged exemption .Any violat ion o r Section 7031.5 b y any applicant for a permit subjects the a pplicant to a civi l penalty of not more than fi ve hundred dollars ($500). _I. as owner or the p ro perty. or my employees with wages as their sole compensation. will do the work nnd t he structure is not intended or o ffered for sale ( Sec. 7044. Business and Professions Code: The Contractor's License Law does not apply to an owne r or t he propc1ty who buil ds or improves thereon. and who docs such wo rk himself or hersclror through his o r her own employees. provided that such improveme nts are not in tended or offered fo r sale. If. however. the build ing or improvement is sold within one year or c ompletion. the O wn er-Builder will have the burden or proving that he or s he not b uild or improve for the purpose or sale). _I. as owner of the propen y. am exclusively contracting with licensed contractors to co nstruct the project ( Sec, 7044. Business and Profession Cod e: T he Co ntractor's License Law d oes not apply to an owner of p roperty who builds or im prove s t hereon . and who contracts for such projects with a Contractor(s} li censed purs uant to the Contractor's License La w.). _I am exempt under Section ________ .B. & P.C. ror this reason. Oitt c: _____________ Owner: _________________ _ W ORKERS COMPENSA TION DECLARATION I hereby affirm under penalty or perjury o ne o f the fo llowing dec laratio ns: _I ha ve and will maintain a Certificate of Consent to Self-Insure for workers' compensation. as provided for b y Sect ion 3700 of the Labor Co de. fo r the performance or the wo rk for which the pcnnit is iss ued . _I ha ve and will maint.1in w orkers· compensa t ion ins urance. as require d by Section 370 0 or the Labor Code. for the performance or th e work for w hic h t his permit is issued. My workers' com pensat io n insurance carrier and policy numbe r arc : Carrier :_•..,_,_/},-=,.( <f=-. n_(1_Ll_t ___cfu=-.=s =u r=a _n c_;:e____;Cc_'D ____ t I Polic y Number: • \IV(, Y L{ '6 l q CoY 7 () \ 14 Expires: ' \'O l 2.fJ / 7 (This section need no t be completed if the pennit is for One hundred dollars {SI OO} or less)----+---1~'--.,_- _I cc1ti ry t ha t in t he performance or the work for which th is permit is issued. I shall not employ any person in any manner so as to became subject to the workers' com pensa tion laws of California . and agree that if I s ho uld become subject to the workers' compensation provisions of Sect ion 3700 of the Labor Code, I shall, forth with comply with those provis ions .. Oat e:_' ____________ .Applicant:_-L==::.._ __________________ _ WA RNING : Failure to secu re workers' compensation coverage is un lawful. and shall subj ect an e mp loyer to criminal pena lt ies and civil fines u p to one hu nd red thousand d o Uars {$100.000).in addition to the cost o f compensat ion. damages as provided forthe Section 3076 or the Labor Code. interest and attorney's fees. LICENSED CONTRACT ORS DECLARATION I hereby affinn under p enalty o f perjury that lam licensed under provision of Chapter 9 (commencing w ith Section 7000) of D ivision 3 or the Busine ss and Pro ressions Code. and my license is in fall force and e ffect. • vli..\1lC~O Licens e Class: • C 3\o Date '2.. \ u,\ 2, Ol \./ . I L icense Number _______________ _ CONSTRUCTION L ENDING AGENCY J hereby affirm under penalty o r perjury that there is a construction le nd ing agency for th e perfonnance or the work for which this permit is issued (Sec. 3097, Civ. C .). Lender's Na me : _________________________ _ Lender·s Address: _______________________ _ APPLICANT'S DECLARATI ON Demolition Pcnnits-Asbcstos Notifi ca tion Federa l Regulations (Title 40. Pan 6) _ Required Letter of Notification [ _---,~t ha t the foderal regulat ions regardin g as bestos removal arc not applicable to this project ,_R_o_u_g_h __ M_e_c_h_. __________ -+-------->------+------------------~ ...... t ~ertify that I have re ad this application and state that the above infonnat ion is correct. I agree to comply with all Cit y and County Final Test ordmanccs and State Laws re latmg to bu1ldmg construction. and he reby~uthonz cpres 1at1ves ofth1s C ity a nd County to e nter u pon the above mentioned property for mspect1on~es._/ ~ I ! Meter Release / / Apphc ant or agent Sig ~ ~ / ~ Date / z. _l.--Z.. [;!-di b I-F-IN_A_L-----~(R-/+..I"-6___...,..R_S_.~_I -.,,.+-1fl-_JL01-f-.--+-q,_-_<{ _______ _. l'ermi11ce name(print):_~~-----1/D-; ;~la~f'\~~-·'_ck~o._r_d_'1 ____ 1 __ • __ I 7 M:\WP51 \Permtt-lnspecUon Forms\Mechanical-lnspector Record.doc 03.31.06