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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/$IG COMMENTS OWNEN, BUILDEN DELCARATION <br />I hercby 8ffrm under Fnalty of perjury that I m exempt fmm the Contractos' Liccne trw for thc following ttarcn (Se.fltsI.s <br />Busincss and Profssion Codc): Any City or County which requircs a pmit lo @nstruct. alto, imprcw. dcmllsh or rcJnir my <br />structurc. prhr to its issuarce. also rcquircs the applicsnt for such [Emit to filc 8 signed ststemnl th8t he or dE ir lienrcd pusuet <br />to thc ppvisions of the Contretor's Liccnsd Law (Chapter 9. Commcrcing with Sslion 7000 of Division 3 of the Busircss 8nd <br />ProfessioN Code) or that hc or shc is exempt tlwfrom ed the besis for thc albgcd excmpion. Any violation of S6tion 7031.5 by 8ny <br />applicrnt for o pcrmit subjets thc applicsnt to 8 civil penllty of not mrc than five hundrd dollars ($500). <br />_1. as owner of the propcrty. or my cmployees with wages as lhcir solc com[rcnsation. will do the work ud the stnrture ls not <br />intcnded or offercd for sale (Ssrc.7M4. Business and hofcssions Code: Thc Contractor's License [.aw does not apply to an owncr of <br />thc propcrty wln builds or impmves thcreon. and who does such work hirnself or hersclf or through his or her own ernployees. <br />provided that such improvenrcnts Bre not intendcd or offercd for salc. If. howcver. thc building or improvernent is sold within one )rcar <br />of completkrn. thc Owrrcr Buildcr will have thc burdcn of proving that he or shc did not build or improrrc the proprty for the purposeof <br />sale). <br />_1. as owner of thc propcrty. am exclusively contracting with liccnscd contraclors to construct thc proicl (Scc. 7W. Business <br />and Prufession Code: Thc Contraclor's Liccnsc Law does not apply lo an owncr of propcrty who builds or improves thcreon, <br />and who contracls for such projects with a Contracto(s) licenscd pursuanl to thc Contractor's Lhcnsc kw). <br />-l <br />am excmpt undcr B. & P.C. for this rcason. <br />l)irlt,. ( )rr ner. <br />WORKERS' COMPENSATION <br />DECLARATTON <br />I hcreby affirm under penalty of pcrjury onc of the following dc.claralions: <br />-l <br />have ard will maintain a Certificate of Consent to Sclf-lnsure for workers' compensation. as provided for by Scction 3700 of the <br />I-abor Code. for the Srerformance of the work for which thc permit Ls issued. <br />-l <br />havc and will maintain workers' compensation insurance. as required by Section 3700 of the l-:rbor Code. for the pcrformance of <br />thc work for which this pcrmit is issued. My workcrs' compensalion insurance carricr and policy number are: <br />Policy Nurrrhcr: Expircs: <br />, <br />_l ccrtify that in thc pertornurncc ol'lhc work for which this pcrrnit is issucd. I shall not ernploy any f,crson in any ltlanncr <br />so as to bccomc subjcct to thc workers'conrpcnsation laws of Califtrrnia. and agree that if I should hccotnc subjcct to thc <br />workcrs' conrlrcnsalion provisions of Section 3700 of thc lahrr Codc. I shall. ltrrthwith comply with thosc provisions.. <br />a <br />WARNIN(]: Failurc to sccure workcrs'compcnsillion coveftrptc is unlawful. and shall suhjcct an entploycr to criminal grcnaltics and <br />civil fincs up to onc hundrcd thousand dollars (Slm.fin). in addition lo thc cosl of contJrcnsation. damagcs as providcd for thc <br />.Scctiorr 3076 of thc Lrtnr Codc. intcrcst attd altorncy's fces. <br />I ):rtc: <br />LICENSED CON'I'R,TCTOR <br />DECLARATI()N <br />I hcrchy altlrrn urrdcr pcnalty of perjury that I arn liccnscd undcr pnrvision of Chaptcr 9 (contnrcncing with Scctiott 7fiX)) of l)ivisittn 3 <br />of thc Busincss und Prof'cssions Codc. iurd nty liccnsc is in full tbrcc and cfft'ct. <br />License Class: Liccnse Numbcr: <br />I)tle: <br />W <br />I hcrcby aflirm undcr pnrlty of pcrjury that lhcrc is a construction lcnding agcrcy for lhc pcrformncc of Ihc work for which lhis lrcrmil is <br />issued (Se. 3097, Civ. C.). <br />lxndcr's Nanrc: <br />[*ndcr's Addrcss: <br />APPLICAN'I' DECI A RA'I'ION <br />I hcrcby allirrn undcr pcnalty of pcrjury <lnc of llrc folkrwirrg dcclaral iorts: <br />Dcnrolit ion Pcrrrrits- Asbcstos Nol ifical ion Fcdcral Rcgulal ions ('Iit lc 40. Part6 ) <br />-Rcquircd <br />Lcttcr of Notilicalion <br />I ccnify thal lhc lcdcral rcfulali()ns rcSuding uslrcskrs rcnxrval arc not opplicnhlc lo lhis prujccl. <br />I ccrtily that I havc rcad this arrrrlicntion ilxl $latc th{t thc athve hlbrmntion is corrccl. I alre lo comply wilh 0ll City tnd Counly <br />oditunccs an(l Slillc hws rclating to building conslruclion. ild hcrcby authoriTr rcprcsenlrlivcs of lhis Cily and Counly h cnlcr uF)n lhc <br />alrw rmnttrncd prolrcny lbr insperti(rn pu]fnss. <br />I Applicant or Agent Signature: Date:- <br />I <br />Pennitcc nanrc ( nrirtl ): <br />Appliances <br />Nletal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />[t/isc. Equipment <br />Duct Work <br />Pre- lnsu Iation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork <br />Vents <br />Toilet Room I Clothes Dryer <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openinqs <br />Installation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release <br />FINAL u. tQ_.20 ffa.loacai 8 <br />Notes, Remarks, Etc.