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MECHANICAL-INSPECTOR RECORD
<br />• APPROVALS DATE ID/SIG. COMMENTS Owncr-Buildi::r Declaration
<br />I hericby affirm under pena lty of perj ury that I am exempt form the Contractors' License Law for the:: following reason (sei;.703 l.5 liusLnc:ss•
<br />Appliances and Profession Codi::): Any C ity or Cou nty which rcquir~ 11. permit lO construct, a lter, improve, demolish or repair any structure, pr\f'r to Us
<br />issuance, also r equires the applicant for such permit to file a signed stale ment that he or sht:: is licensed pursuant to the provisions of the
<br />Metal Fire Place Com:ractor's Licensed Law (Chnpter 9 , Comme ncing with Section 7000 ofOi't'ision 3 of the Business and Professions Cuth:) or thal h,c o r
<br />she is exempt therefrom and the basis fo r the alleged exemption .Any violauon of Se ction 703 1.5 by any applicant for a permit subj ects tht:: Evap Cooler applicant to a c ivil penalty of not more than five hundrl!d do llars (S500).
<br />Furnace _1, as owner of t he property, or my employe(!S with wages as their sole compc::nsation, will do the work and the structure::~ not intended
<br />or o ffered for sale ( Sec. 7044, B ll:iin ess and Professions Code: Thi: Contractor's Licensi: Law does not apply 10 an owner of the property Compressor who builds or impro vi:s thereon, and who does s uch work himself or herself or t hrough his o r her own employees, provic.h:d that such
<br />improvements are no l intended or offered for sale. Jf, however, the building or improve ment is sold wit hin one year of complet ion, the
<br />Misc. Equipment Owne r-Builder w ill have the burden of proving that he o r she not build or impro ve for the purpose o f sali:).
<br />_J, as owner o f the propeny, a m exclusively contracting with licensed contracto rs to construct the project ( Sec. 7044, Busim:ss and
<br />Profess ion Code: The Contractor's License Law does not a pply to an owner ofpropeny who builds or improves diere.on. u.nd who
<br />Duct Work contracts for such proje cts with a Contractor(s) licensed p ursuanl to lhe Comractor's License Law.),
<br />Pre-Insulation _I a nt exempl under Sectiou B. & P.C. fo r this reason.
<br />Insulation Date: Owni:r:
<br />Smoke Detectors In stall ed WORKERS COMPF.NSATION llF.C I.ARATION
<br />I hereby affirm under penalty of perjury one o f the following d eclarat ions:
<br />Rough Ductwork
<br />-l have and will maintiiii n a Ce rtificate of Consent to Sdf-l nsure for workers' compensation, as provided for by Sec1ion 3700 o f the
<br />Labo1 Cod e, for thi: performance of the work for which the pcrmiL is l:isucd.
<br />_I have and will,main1~m• compensation insurance. as requir<d by S«1ion 3700 of1he Labo r Code. for the performa nce of the
<br />wo rk '2Wch ,;is permit s issuro~~111'ier and policy n r are. c1 Vents
<br />Carrier: .7J Cl / Cl/, -\\: -Toilet Room I Clothes Dryer
<br />Policy Numbe r: Expires: Residential Range (This .iection need not be completed if the permit is for One ~J.Jndred d<ffl• rs {$100} o r less)
<br />_t ce~ify 1ha1 in the performance of the ".'ork foitcf'is permit is is ued. I .shall 1101 employ any person in any mann_er so as to Other
<br />became subjec t to the workers· compensauon laws o a llfo rma, a nd agr ~ t t 1f l should become subJt;ct 10 the workl.!rs
<br />compensa~:visions of ::,on 3700 of 1he La r Code, J shall, fo'}i w~ with those provisions..
<br />Hood Dai~\ ( "5'": ( b Applic.m -' -.
<br />Type I Hood WARN ING: Failure to secure workers' compe nsation coverage is unlawful, and shall subject an 1.!mployer to crimimd p~nallil!S and c ivil
<br />fines up 10 o ne hundred thousand dollars ($100,000),in a ddition to the cost of co mpensation, damages as provided for tht.: Section 3 076 of Type II Hood the Labor Code, interest a nd atto rney's foes.
<br />G rease Duct LIO:NSl:D CONTRA!:;T ORS llEC:1.ARATtON
<br />I hereby affirm under penalty of perj ury 1h•1 I am lice nsed under pr~~::,hapler 9 (commencing with Section 7000) of Division 3 of
<br />the Business and B ns Code, and my licen.se is in full for and effect G 6 04 tJ. L/
<br />Fire Damper L1ct.:ns c C lass: . L icense Number
<br />,~-,~,,./ 6 ( _L IX. Date: Conlracrn,. -~-w -Openings
<br />··-..
<br />Installation C ONSTRUCTION u :NDING AG ENC"Y
<br />I hereby affirm undl.!r penalty of pe rj ury that there is a construc tion lending agency for the performance of tht: work for whic h 1his permit is F.D . Drop Test issued (Sec 3097, Civ. C.).
<br />Lender's Name.
<br />L1.!nd1!1 's Address:
<br />Above Hard Lid
<br />APPLIC ANT'S Dt,:CI.ARATl(JN Above T-Bar Demolilion Permits-Asbestos N otifi cati on Federal Regula 1ions (Title 40, Pan 6)
<br />_ Required Leth:r of Notificatio n _, _,, ..... z·ij·-.. ·--···-·--"·" .. ~ •·""" Rough Mech. II\-\ a..-\ l UJ,~~ /~)
<br />_ l certify •11::; ve read this applica11on d state 1ha1 the above mfo rmauon is corr«L I agree 10 comply wllh all Cny a nd Cuumy Final Test -ordinances and late Laws rela1mg lo buildi :;;;;t,,• and hereby authorize representatives uflhis City and County 10 en1or u&
<br />above ment ion d property for inspection p O:"-'· -c9 r ~ -I Meter Release
<br />-Applicant or ag ·· • -..,._,,. ../ ---. / J Dale:_~
<br />FINAL :@,,-2,9,-,/7 Jdek;;. i:.:;:w 'f'II ~ lO(_ la_,.e./7 , Permiu ee name (print}: --
<br />M:\WP51\Perm,t-lnspecUon Forms\Mechamcal-lnspector Record doc 03.31.06
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