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APPROVALS DATE
<br />Appliances
<br />Metal Fire Pla ce
<br />Evap Cooler
<br />ID/SIG.
<br />MECHANICAL-INSPECTOR RECORD
<br />COMMENTS Owner-Builder Declaration
<br />I hereby affirm under penalty of perju ry that I am exempt form the Contractors' L icen se L1w for t he followin g reason (sec. 7031.5 Bus inc~s .
<br />and Profession Code ): Any Cit y or County which requires a permit to construct. alter. improve. demolish or repair a ny struc-1 ure. prior to its
<br />issuance. also require s the applicant for such pennit to lile a signed statement that he or she is licensed pursuant to the pro visions o i the
<br />Contractor's Licensed Law (Chapter 9. Co mme ncing with Section 7000 of Division 3 of the Business and Professio ns Code) or that he o r
<br />she is e xempt therefro m and the basis for the alleged exemption ,Any v iolat ion of Section 703 1.5 by any a pplicant for a pennit subjec1s the
<br />applicant to a civ il penally o f not more than five hundred dollars ($500).
<br />Furn ace _I. as owner o f the propcny. or my employees with wages as their sole compensation. will do the work and the structure is no t inte nded
<br />or offered fo r sale ( Sec. 7044, Business and Profess ions Code: The Contractor's License Law does not apply to an owner of the prope11y C w ho builds or improves 1hereon. and who d oes such work himself o r herself or through his or her own e m p loyees. provided that such OmpreSSQr improvements are not intended or offered for sale. If. ho wever. the building or improveme nt is sold within one year of comp letion. the
<br />._M __ is_c_._E_q---'-u_i__cp_m_e_n_t _________ ._ ______ _,_ _________________________ _,~r-Builder will have the burden of proving that he or she not build or improve for the purpose of sale).
<br />as owner of the p ropeny. am excl us ively contracting with licensed contractors to construct th e projecl ( Sec. 7044. Business a nd
<br />~-------------------1---------l---------l------------------~ rofession Code: The Contractor's License Law does not a pply co an owner of property who builds or im proves thereon . a nd who
<br />Duct Work
<br />Pre-Insulation
<br />Insulation
<br />Smoke Detectors Installed
<br />Rough Ductwork
<br />contracts for such p roj ects with a Contractor(s) licensed p ursuant to the Contractor's License Law.)
<br />o.,:,•m i 2ltc1;,·:,1_ /----0,-vne-r -~~~~~L-~> ·o~
<br />. l / •-r u
<br />WORKERS COMPENSATION DECLARATION
<br />I hereby affirm under penalty of perjury one o f the follow ing declarat ions:
<br />_I have a nd w ill maintain a Certific ate of Consent to Self-Insu re fo r wotkers' compensa tion. as prov ided for by Sect ion 3700 o f t he
<br />Labor Code. fo r the performance of the work for which the permit is issued .
<br />_I ha ve and will maintain workers· compensation insurance. as required by Section 3700 of the Labor Code, for the performance of the
<br />work for which this permil is iss ued . My workers· com pensation insura nce carrier a nd policy number are :
<br />Vents r \ Carrier: __________________ _
<br />Toilet Room I Clothes Dryer 4-t}'·--/; Jr<\.JiJ~ PolicyNumber E,pires: _____ _
<br />Residential Range u ( '---7 ~cl ion need not be completed if the pennit is for One hundred dollars !SIOOi or less)
<br />~Q--th_e_r -------=----------4---------1------+-------------------4 rtify,tlrnt in the perfonnance of the work for which this permit is issued. I shall not employ any person in any manner so as to
<br />~--------------------1--------4--------1>---------------------1 subject 10 the workers· compensation laws o f Californ ia. and agree t ha t if I should become subject to the workers·
<br />Hood
<br />Type I Hood
<br />Type II Hood
<br />Grease Duct
<br />Fire Damper
<br />Openings
<br />Installation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />compen sation r;:ov¼•iji o ns of~~'; 3700 o f the Labor Code. I sl~~.:ply with th:se ~~ion~/ __
<br />Date: /.Z./i ///.,,,,,, Applican1 :K/ A/"·c,,,,,, .,,,,,,,,_u, -J ~~
<br />WARN;NG : l ilure ,{secure workers· compens:ition coverage is unlawful. and sha ll s ubject an employer to cr::O.na lties and civ il
<br />fi nes up to one hundred thousand dollars ($!00.000).in addit io n to the cost of compensation. d amages as provided for lhe Sect ion 3076 of
<br />t he Labor Code, interes1 and anorney·s fees
<br />LICENSED CONTRACTORS DEC L ARATION
<br />I hereby affirm under penalty of perjury that I am licensed under provision o f Chap ter 9 (commencing with Section 7000) of Division 3 of
<br />t he Bus iness and Pro fessions Code. and my license is in full force and e ffect.
<br />License C lass.: ______________ License Nu m ber _______________ _
<br />Date: _____________ Contractor: ____________________ _
<br />CONSTRUCTION LENDING AGENCY
<br />I here by a ffim1 u nder penally of perjury tha t th ere is a constrnction lending agency for the perfon nance o f the work for which this permit is
<br />issued (Sec. 3097. Civ. C.).
<br />Lender·s Name: _________________________ _
<br />Lender's Address: _______________________ _
<br />APPLICANT'S DEC LARATION
<br />Demolition Pennits-Asbestos Notification Federal Regulations (Title 40. Part 6)
<br />_ Required Letter o f Notification
<br />1--------------------1--------4--------t-------------------,/_(iY ert ify lha t the federal regul ations regarding asbestos removal are not appl;cable to this project.
<br />~R~o~u~g~h~~M~e~c~h~-----------.l-------L-----L----------------"::::11~¥-Lfj,'_I ccn1fy that I have rea d this appll ca11on and Slate that the above mformat 1on IS correct [ agree to comply w ith all City and County Final Test ordmances and State Laws rela~mg to 1ldmg conslnu:t1on. and hcr~thonze 1epresentalives ofth1s Ctty and Count to enter upon the
<br />above mentioned propeny fo r "ct1 pu oses ~ ...,.,...-: 7 .._ _ _ :;;> // ,I/
<br />Meter Release A t0 Apphcantoragents,g. '><t'./4 ·rv,~v'?-tP 7'-X Date • I ~,,,¢/1/r.-..
<br />FINAL (n....-'2--a ---\1 1~0_~'), ~ Pcrmittecname(print):"' //~ ~~ -~{ f
<br />V UU
<br />M:\WP51\Perm,Hnspect,on Forms\Mechanical-lnspector Rec ord.doc 0 3.31.06
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