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M ECHANICAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER AUILDER DELCARATION <br />I haeby affurn unda poalty of perjury thal I m cxempt from thc Conlractors' License Law for thc following te@n (54,7031.5 <br />Busins md Prcfsion Code): Any Ciry or County which rcquire a pcmit lo srulruct. Eltq. improve. dc'iholish or rqtir oy <br />structuc. prior to its i$uece. slso requirs the applicant for such pemit to filc a signed statmmt that hc or shc b licms€d psuilt <br />to the provisiom of thc Contractor's Licened [:w (Chapter 9. Commcncing sith Sation 7000 of Division 3 of thc Busins md <br />Prefsions Code) or that hc or she is cxempt thqcftom md the basis for the alleged excmpion. Any violation of Scction 7031 .5 by any <br />applicantforapomitsubjslsthe applicanttoacivilpcnaltyofnolmorelhelivehundreddollus($500). <br />-1. <br />r o*nc of the Fopcny, or my employm with wagc r their mlc comprmtion. willdo thc \rcrk md rhc stnrc{w is nol <br />intqrded or offscd for sle (Sa,7044, Businas od Profesiom Codc: The Contractor's LiceN law do6 nol apply to il orvner of <br />lhc prcperty who builds or improv€ th@tr drd who do6 such rvork himself or heelf or through his or her own cmployG. <br />provided rhat such imprcv@mts sc not intoded or ofrs€d for slc. I[, howqq. thc building or improveml is sld *'ithin onc ]q <br />ofcompletion. the Olws Buildq will hare thc burdan ofprcring tha hc or shc did not build or improvc thc prepoty for thc prrpose of <br />ele). <br />-1. <br />r owna of thc propcty, an cxclusivcly contr8cling with liceBcd contractoE lo costruct the projcct (Ss. 7044. Buins <br />ud Profissbn Codc: The Contrsctor's Licose L8w do6 not apply to il own6 ofproperly rvho builds or inprovG th6@n. <br />md who conlnc-ts for such Fojcts with a ContEcto(s) licqscd purswt to thc Contractor's Licffi Law). <br />-l <br />m cxctnpt unds Setion-. B. & P.C. for this re6on. <br />f\^. ^. <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hereby affrnn under penalty of perjury one of the following declarations: <br />-l <br />have and will maintain a Certilicate of Consent to Sclf-lrsure for workers' conlpensation, as providcd for by Scction 3700 of the <br />L,abor Code, for the performance of the work for which the permit b issued. <br />-I <br />have and will maintain workers' comperration insurancc, ost required by Section 3700 of the l-abor Code, for the pcrformance of <br />the work for which this permit is issuod Myworkers' compcnsation insurance carrier and policy numk are: <br />Policy Numbcr: ExPires: <br />_l certi& that in the performance of the work for which this permit is issued. I shall not cmploy any person in any manner <br />so as to bec'ome subject to the workcrs' compensation laws of California and agree that if I should become subject to the <br />work€rs' compensation provisions of Sedion 3700 of the Labor Code I shall. forthwith comply with those provisions.. <br />WARNING: Failure to sccure work6s' compensation coverage is unlawful. and shall subject an anployer to ciminal pcnalties and <br />civil fines up to one hundred thousand dollars ($100.000). in addition to thc cost of compensation. damagcs as provided for the <br />Section 3076 of the labor Codc interest and attorney's fecs. <br />LICT'NSED CONTRACTOR <br />nF.T.LARAT|ON <br />t hoeby aflirm und6 peoalty of pcrjury th* I am licenscd under provision of Chapter 9 (commencing with Seaion 7000) of Division 3 <br />of the Business and Professions Code, and my license is in full force and effcct. <br />License Class: License Numbcr: <br />ll^ . ^.ftnnlrontlar. <br />W <br />I hrcby affm undu pculty of pqjury th8t thm is I ortslruction lctrding agmcy for thc pcfomcc of thc work for which this porit b <br />Civ. C.). <br />l'ender's Address: <br />^ rr, ,c N, "rc, RAT, <br />I herdry affrrn under penalty of perjury one of the following declarations: <br />Dernolition Permits-Asbestos Notification Fcderal Regulations (Title 40. Part6) <br />-Required <br />Letter of Notification <br />-l <br />cEtiry thd rlE fcd6.l rcgulatiou rcgrdiog ubctos moval e lot pplicsblc to thb ptoj61. <br />-l <br />6tiry thst I havc ud this application [d statc thrt thc abovc infomdion is cotrE{. I agrc to 6mply with Ell City 8td Couoly <br />ordimce ed Statc Lam rchtiry to building constnctioq ad hqcty autlbriE rcpr$mrive of thir City ud Couty to 6ta upon rhc <br />abovc Mtiotrcd popaly for iBpoctioo purpca <br />Applicant or Agent Signature: <br />l'r'r nrilct' r)iunc (pr irrl) <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type Mood <br />Grease Duct <br />Fire Damper <br />Openings <br />Installation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release l .A <br />FINAL ll la{l 2d Dkr ry <br />Notes, Remarks, Etc. <br />Carricr: