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M ECHANICAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hqcb affrm undo pcnalty of pcrjury thst I m crmpt ftom thc Contnctos' Licffi t w for thc following ren (Sc.7031.5 <br />Buincs and Proftsion Code): Any City or County which rcquirc a pamh to corotruct, alt6, improvc &rnolish or rtpair uy <br />structuq prior to its isuucc, rlso rcquirc thc applicmt for such pcrmit to filc r signcd statmdt thal hc or shc b lic$cd pwant <br />to thc provisiom of thc Contractor's Licascd trw (Chafla 9, Commcncing with Sction 70fi) of Division 3 of thc Buin* ed <br />Prcfssions Codc) or that hc or shc is cx€mpt thcrrfrom md thc b6sis for thc allcged amptio[ Any violatioo of Scclion 7031.5 by sy <br />applicant for a pcmit subjBts thc applicel to a civil pf,ally of nol morc tha fivc huodrcd dollm (S500). <br />_t. as owner of the property. or my employees with $'ages as their sole cornpensation. s'ill do the rvork and the struclure is not <br />intende<l or offered for sale (Sec.7044. Business and Professions Code: 'l'he Contractor's l-icense las'does not apply to an orvner of <br />the progloly s'ho builds or improves thermn. and u'ho does such \r'ort himselfor herself or through his or her ou'n employees. <br />providcd that such improvernents are not inlsrded or offered frrr sale. ll. hos'ever. the building or improvernenl is sold rvithin one y'ear <br />of conrplction. the On ner tluilder will have the burden of proving that he or she did not btrild or improve the propo1y for the put'pose of <br />sale). <br />_1. as o\\'ner of the property. arn exclusively contracting s'ith licensed contractors lo constntct the Jnoject (Sec. 7044. Businers <br />and Prnftssion Code: The Contractor's License Las' does not apply lo an o$'ner of property u'ho builds or improt'es thereon. <br />and rvho contracts lor such projecls rvith a Contracto(s) licensed pursuant to the Contractor's l,icense Law). <br />-l <br />am exempt under Section- <br />-. <br />B. & P.C. for this re&son. <br />Date: _ Owner:_ <br />WORKERS' CONI PENSA'TION <br />DECI,ARA'IION <br />I hereby affrrm under penalty of perjury one oIthe follorving cleclarations: <br />_l have and s'ill maintain a Certilicate of Consent to Self-lnsure for s'orkers' cotnpensation. as provided for by Sec'tion 3700 of the <br />l-abor Code, for the perfonnance of the work for rvhich the pennit is issucd. <br />4 <br />the <br />have and will maintain rvorkers'insurance. as by Section 3700 of the labor Code. for the performance of <br />carrier and policy numh are:rvhich <br />'xpires: <br />jJ-L"2ldPolicy <br />_l cerrify that in the performance of the rvork for rvhich this grrmit is issued. I shall not employ any person in any manner <br />so as to become subject to the workers' compensation laws of California. and agree that if I should become subject to the <br />workets' compensation provisions of Section 3700 of the labor Code. I shall. forthwilh comply rvith those provisions.. <br />\ <br />WARNING: Failure to secure workers' compensation coverage <br />civil fines up to one hundred thousand dollars ($100.000). in <br />is unlawful. and shall subject ur onployer to oiminal penahies ,tnd <br />addition to the cost of compensation.damages as provided for the <br />attorney's fees. <br />LICEN SED CON'I'RAC'I'OR <br />DE(ILAR/tI'l()N <br />I hereby alTirnr under penalty of periury that I arn licensod undcr provision of Chaptcr 9 (ct'rtnmencing rvith Seclion 7000) of Division .l <br />of thc Business and Prof'essions ('ode. and my license is in full force and effect. <br />License <br />,",.,tt [t<lto( <br />W <br />I hrcby aflim undr penalty of pqjury that th6c is a construclion lilding agmcy for thc perfomocc of thc s'ork for rvhich this pcmit b <br />issucd (Sc. 3097. Civ. C.). <br />l.crrtlt'r's Narnc <br />Lendcr's Addrcxs: <br />&ErcAII.DECIAEAIIO! <br />I harbyalfrm unda pcoally ofpsjury one ofthe following deluations: <br />Demolition Pmits-Asbcstos Notirication F€dml Rcgulations (Title 40. Pan6) <br />-Requircd <br />lrtls of Nolifi calion <br />-l <br />cdify thd thc fcdral rcgulatioro rcgrding rbetos rmoval rc not applicsble to this prcj€r. <br />_l ccrtifythat t have rad this application ild statcthat thc atnvc infomation is corcl. I sgre to smdy wilh sll City 8nd County <br />ordinancG and Statc tsw3 rclatirg to building coNtruction. atd hseby authorizc rcprffitalilc of this City md County to 6lq upon thc <br />above mentioned property for <br />o,r",\tlcs/qApplicant or Agent <br />Pennitee name I <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 l-22-?o s*2Dr\ <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Range <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 <br />FINAL /-?'l-?)*4 l€? <br />Notes Remarks Etc. <br />;::"fituffiTq Applicant:- <br />-Lic< <br />Nconrracro,,K'8f;31[ *r-rl