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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE !D/SIG.COMMENTS OWNER BUILDER DELCARATION <br />t h6cby affm und6 poalty of pcrjury thri I m ampt ftom thc Coilraclor' Licre Law for the following ron (Ss.7031.5 <br />Bwincs ad Prcfsion Code): Any City or Couily which rcquiE . pamit to ondruc{. alto. impmvq damlbh or npair ay <br />structuc, Fior to its isumcc. also rcquira thc applictrt for such pcf,trit to 6lc 8 signcd 3td@6t tha hc or slrc is licascd pmut <br />to thc p,ovbioN of thc Contrrctor's Licm*d kw (Chsplq 9. Commmcing with SBtion 7000 of Division 3 of thc Busins fid <br />Profcssions Codc) or thrt hc or shc is qmpt thqc*om od thc bBL for thc 8lk?od qoplioo. Any violaion of Setion ?03 I .5 by my <br />appticantforapmitsubjctsthc spplicantto.civilpcmltyofnolmorcthufivchundrcddollmO500).I <br />-1. <br />as owner ofthe properly. or my with wages as their sole compcxsation. rvill do the rvork and the slnrcttne b not <br />and Professions Code: The Contraclor's Liccnse Law does not spply to an ou'ner ofintended or offered for sale (Sec. <br />the property who thereon. and rvho does such rvod<himself or herself or through his or her orvn employees. <br />lf. horvevcr.lhe building or improvetnert is sold rvithin one )€arprovided that such are nol intended or offered for sale. <br />Builder will have the burdcn of proving thd he or she did not hrild or impnove the propcrty for ttrc purposcof <br />sale). <br />antl <br />, as owner of the property. am exclusively conlracling s'ith licensed contractors to construct the project (Sec. 7044. Business <br />Proftssion Code: The Contractor's License Law does not apply lo an owner of property s'ho builds or improves thereon. <br />rvho contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License Law).and <br />-I <br />under B. & P.C. for this reason. <br />l)r:('l-All^ ilON <br />I hereby allinn under penalty declarations: <br />_l have and rvill maintain a Certificate of Conscnt to Self-lnsure for workers' compersalion. as provided for by Section 3700 of the <br />kbor Code. for the performance of the rvork for rvhich the pennit is issued. <br />-l <br />have and 3700 of the Labor Code. for the perfonnance of <br />the rvork for and policy number are: <br />Policy I:rpir cs: <br />certify that in the perlormance of the rvork for which this perrnit is <br />of California. <br />issued. I shall not employ any person in any manner <br />so as to become subject to the workers'compensation laws and agree that if I should betome subject to the <br />, forrhu'ith comply s'ith thosc provisions..rvorkcf,s' compensation provisions of Section .i700 of the Labor Code. I shall. <br />WARNTNG: Failure to sc<ure rvorkers' compensation coverage <br />civil l'rnes up to one hundred thousand dollars ($100.000). in <br />is unlarvful. and shall subjec an employer lo oiminal perulties and <br />addition to the cost of compensation. damages as provided for the <br />Section 3076 of the Labr Code. interest and fees. <br />I hereby affrm under penalty of perjury that t arn ticensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code. and my license is in full force and effect. <br />License Nunrber: <br />l)alc: ('oltlt'nclor: <br />W <br />I hcrchy affinn undo pcnahy of psjury that th6c is a conslruction lqding agency for the pqfonnancc ofthe rvork for rvhich this pmnit is <br />issued (S(. 3097. Civ. C.). <br />Lender's Address: <br />APPLICANT DECLARATION <br />I hercby aftm under penalty of perjury one of the follorving declarations: <br />Dernolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Par6) <br />_Required Later <br />I the federal regulations regarding asbestos removalare not applicable to this projed. <br />l read this application and state that the above infonnation is correct. I agree to comply rvith all City and County <br />ordinarrces Larvs rclaling construction. and hereby authorize representatives of this City and County to enter upon the <br />abo0e <br />Applicant or <br />Perrnitee <br />[or purposes. <br />_,-", l, *5-L0 I! <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-!nsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranse <br />Other <br />Hood <br />Type I Hood <br />Type ll 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 I h il,,2 <br />FINAL 31ag-- <br />a )r tlal'zo DtfYfilflfrr <br />Notes Remarks Etc.I I lv <br />aa (-.rt/"' '* <br />I <br />4tl tU;lslt ) <br />)rutu