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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER Di:I,CARATION <br />I hcrcby allirn u[der pcnalty of pcrjury thal I um crcmpt from lhc Conlrilcl(,s' Liccnrc law for thc following rcason (54.7031.5 <br />Busincss ard Profcssion Codc): Any City or County which rcquircs a Jrcrnrit to mnslruct. altcr. improvc. dcdrolish or rcp4ir any <br />slructure. prior lo its issuancc. rlso rcquircs the applicant for such lErmit kr lilc a signcd slolcrrctrt lhnl hc or shc is liftnsd pursunnl <br />tr thc provisi()ns of thc Contrnctor's Liccnscd lnw (Chuplcr 9. Connnercing with Scctk]n 7UD of Division 3 o[ lhc Busircs$ aRl <br />PrelbssionsCodc,orlhnthcorshciscxcnrpllhmtiomandlhchasislirrthcallcgctlcxcuplion. AnyviolalionofScctionT0-ll.5byany <br />applicanr lor a fcrmir subjccls rhc applicant to o civil pcnally of not nnrc lhnn livc huudrcd dolhrs ($5il)). <br />_1. as owrcr of thc pnrJrcny. or my cnrpkrlecs with wagcs as thcir vrlc conrpcnsation. will do thc *ork ard lhc slfflurc is [)l <br />hlte[dcd or otlcrcd lbr $lc (Sc.?(]44. Busincss and Professions Crxlc: Thc Conlructor's l-iccnsc Law docs nol apply lo an owncr ol' <br />thcpnrFny wlxrhuildsorirrprovcslhcr&tr.ilfflwhodocssuchqrrkhitrrsclforhcrsclforlhroughhisorhcrownemployccs. <br />providcd lhrt $uch impn)vcrmnts m not inlcndcd oroflbrcd for elc. ll: hoscrer.llrc huihing or inrJrnrvcrrcnl is wU wilhin orc }{d <br />ofcotrplcthn. thc Owncr Buiklcr will havc lhc burdcn ofprevinS lh{l hc or shc did ml build or imprcrc thc pmFny for lhc purFi$ of <br />srh). <br />_1. ils o$'rcr of thc propcny. amcxclusivcly conlraclilg wilh liccnscd conlrnclors l() conslrucl thc proFct (Scc. ?O44. Busincss <br />aml FotbssimCodc:ThcConlrackrr'sLicerseLuwdocsnotrpplyloanosncrofprolxrlywhobuildsorimprovcslhcreon. <br />rnd who contraclsforsuchprojslswilhaGnrlmdo(s)licc[scdpursuanlk)lhcConlrackrr's]-iccnsclaw). <br />-lantcxcnnilu[dcrsccli()n-.B.&P.C.forlhisIeasnl. <br />Owner:wtrRxsmtlx <br />DT'CLARATION <br />I hcrcby allirm undcr pcmlly of pcrjury onc of thc followir[: dcclilal ions: <br />[l harc and will roiltain a Ccnilicilc of (lonrcnt ro sclf-lnsurc lor uorkcrs'com1rcnsdion. as previdcd for hy Scclion.]7{x) of lhc <br />litnr C(xlc. lbr thc plrformncc of lhc $ork fbr which thc pclmit is issucd. <br />il/ <br />Al havc ond will maiilain workcrs' conqrnsation insurnncc. ds rcquircd hy scclion 371x) ofthc tahor Codc. for lhc pcrlbrn[ilrcc of <br />thc work for whk'h lhis pcrnrit is issml. My workcN' (nnpcnsalitrn imurrnce canicr a[l Fllicy numher ec: <br />kd <br />Policy oxlzzlZ ^ r <br />K .*.rify rhat in rhe performancc of thc work for which this Jrcrmir is <br />so as to trcomc subject to the workcrs'compcnsation laws of California. <br />issucd. I shall not cmploy any Frcrson in any manner <br />and agrce thnt if I should bcconrc subjcct to thc <br />workcrs' compcnsation provisions of Section 3700 of thc Labor Codc. I shall. forthwith comply with those provisions.. <br />WARNING: Failure to sccurc workcrs' conl;rcnsation covcragc is unlawl'ul. nnd shall subjcct an crnploycr to criminal pnahL's and <br />civil lincs up to onc hundrcd thousand dollars ($100.fin). in addition to thc cost of cont;rcnsation. danugcs as providcd for thc <br />Scction .3076 of lhc Lahrr Code. intcrest and attorncy's fecs. <br />D,r", lo [2q lzo <br />LICENSED CON'TRACTOR <br />DT'CLARATION <br />I hcrchy alfirrn undcr pcnalty of pcrjury thal I arrr liccnscd unrlcr provision of Ch:rptcr 9 (cottuttcttcing with Section 7Un) of Division 3 <br />o[ thc Busilrcss and Prol'cssions Corlc. arxl rny liccnsc is in full ltrrcc antlcll'ccl. <br />omb n5LiccnscNumhcr: <br />C(INS'I'RUCTI(IN LENDING AGI'NCY <br />I hcrchy [flirm uodcr lEnnlty ofpcrjury that lhcrc is a conslruction hndilg agcncy lbr lhc lrcr[ormoncc oflhc work for which lhis ttrtrtil is <br />issucd {Ss. 3097. Civ. C.l. <br />Lender's Name: <br />l-cndcr's Addrcss: <br />APPLICAN't I)ECLARA'I'ION <br />I tr'rcby atlirnr untlcr pnulty ol' pcrjury onc of thc frrlkrwing dcclarat ions: <br />Dcrrxrlition Pc'rrnits-Asbcslos Notificalion Fcdcral Rcgulations ('l'itle 40. Pan(r) <br />-Rcquired <br />l-cltcr of Notitication <br />-l <br />certify that thc fedcralrcgulutions rcgarding asbcstos rcrncrvalare not applicabh to lhis prnjcct. <br />-l <br />ccnify thal t have rcad this opplication &d stsle thol the abovc informlion is corcct. I aSre to mmply with all City and Counly <br />ordinonccs snd Stalc liws rcl8ting to building constludion, ud hc]cby authorizc rcprercntdives ofthis City snd Counly to cnts uF,n thc <br />atxlvc nrcntioned property for inspcction purg)ses. <br />Applicanl or Agcnl <br />permitce namc (print r, AatAnlLq ftlt, a S <br />Appliances <br />[Vletal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />ItIisc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork <br />Vents <br />Toilet Room I Clothes Dryer <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type Il Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release rl l -.D <br />FINAL Ir It,l',1,?TTY V / <br />Noles,,Remarks, Etc. I <br />I <br />.A <br />I L '?a) -/ Vkvll{-,\'12rfi I ,-/trTl bft*Kq <br />I \v \ <br />1 -)O2D _Expircs: <br />o,,", rclzn [)o <br />!