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M ECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/S!G.COMMENTS OWNER BUILDER DEITARATION <br />I h6cty affm und6 Frulty of pcrjury ths! I m qmpt from lhc Conirelw' Licce t:w fur thc followitg tumn (54.7031.5 <br />Bwine ard Profeion Codc): Any City or County which rcquire a pcmh lo ooltruct. altq. improvc damlish or rpair uy <br />stsuc{urc. prbr to its issmcc. al$ rcquic lhc applicet for such pcrmit to filc I signcd $almmt ihlt hG or Ct b licascd pwrtn <br />to thc provisioB of thc Cootnctor's Licoscd Lrw (Ctrpt6 9. Comocing with Sction 7000 of Division 3 of thc Buirc ud <br />Prcfc$ions Codc) or thd hc or she b qcmtr thccfrom ed thc bssis for thc sllelcd smplion. Any violation of Scrion 7031.5 by ey <br />appliciltforrpcf,nitsubjclsthc spplicEnttoacivilpcnaltyofnotmorcthmfivchundrcddollus(3500). <br />99 t, * o*o of ttr" propcily. or my ffiploym with wags r thcir rclc ompasation, will do thc md( Ed thc structrc b rct <br />intodcd or olIacd for slc (Sc.7044. Buiae md Profsioro Codq Thc Conlrsclor's Licme [:w do* not eply to u om6 of <br />thc popaty who tuildr or improvB thqa[ ad who do6 such wlt hirelf or hffilf or thrcugh his or hr om mployc. <br />providcd thst such imprcvqtHN e mt intad.d or otfqcd fur slc. lf, how, tlE tuildiru or irprovcnrnt is sH within orc try <br />ofconpllioo thc Ovna BuiEa wil h.rc ttE burd6 ofproving thd hc or sh€ dit mt buiH or irprovc lhc propsty 6r thG Frpoe of <br />sb). <br />_1. as owner of the propefly. arn exclusively contracting u'ith licensed contractoni lo construct the project (Sec. 7044. Business <br />and Prloftssion Code: The Contractor's License Larv does not apply to an owner of property who builds or improves thereon. <br />and who contracls for such projects with a Contracto(s) licensed pursuant to the Contractor's License Law). <br />-- _l arn cxcnrpl un(lcr Sccliott . l]. & l'.('. for lhis rcasort. <br />Dnre: lllogl l1 orvner: ,r,.r,.*,ror,#.ii,un <br />-|g1r,,tnl't.ltrx <br />I herctrv a{Iirru urrrlcr pcnaltv of pcrjury onc oItlte lollorr ittg rlcclatations: <br />-l <br />have urd will maintain a Certificate of Conscnt to Self-lnsurc for workers' compcnsation. 8s provided for by Section 3700 of the <br />I-abor Codc. for the performance of the work for which the pomit b issued. <br />_l have and will maintain workers' compensation insurance. as required by Section 3700 of the kbor Code, for the pcrformance of <br />the work for which this pcrmit is issued. My workers' compensation insurance carier and policy numb are: <br />('irrr icr': <br />Policy NI.,.-L*.l'rPilcs <br />(!t ceniry that in the performance of the work for rvhich this perrnit is issued. I shall not ernploy any person in any manner-sb <br />as to become subject to the workers'compensation laws of ('alifornia. and agree that if I should become subject to the <br />u'orkers' compensation provisions of Section -1700 of the Labor Code. I shall. forthrvith comply wilh thosc provisions..I <br />WARNING: Failure to sccure rvorkers' compensation coverage is unlarvful. and shall subject an employ'er to criminal penalties and <br />civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. damages as provided for the <br />Section 3076 of the tabor Code. interesl and attorney's fees. <br />I <br />urt.r [, Ot' l1 <br />LIC ENSED (:ONTRAC'I'OR <br />DE('LARA'IION <br />I hercbyaffirm uncler penaltyof perjurythat I arn licensed under provision of Chapter 9 (cotntncncing s'ith Section 7000) of Division l <br />of the llusiness and Proficssions Code. and my license is in fiull force and effect. <br />License Number: <br />CONSI'RUC'I]ON I,ENDING AGENCY <br />I horby aflirm under tmalty ofpqjury that thqe is I conslruction lending agency for the pqfonnancc ofthe work for *hich this prrnit h <br />issued (Sec. 3097. ( iv. C.). <br />Lender's Name: <br />Lender's Address: <br />APPLICANT DECLARATION <br />I hcrdryaftrn under penalty of perjury one of thc following declarations: <br />Demolition Permits-Asbcstos Notification Federal Regulations (Tillc 40. Part6) <br />-Required <br />Later of Notification <br />--l <br />cstify that lhc fcdsal rcgulations regtrding asbslos remrrval are not applicable to lhis prejBt. <br />tLI cotify that I have read rhis application ild stale that (he above infonnation is cor$l. I agre lo conrply with all City and County <br />ordinancB and State l,arvs relating to building construction. md hcrcby authorize reprGcntativs oflhis City and County to ql6 upon lhe <br />above mentioncd propeny for inspcction purpos6. <br />Applicant or Agent <br />Pennitee niune <br />og . tg <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 Range <br />Other <br />Hood <br />Type I Hood <br />Type II 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 />I i I <br />Roush Mech. rt l2s lltl P/-/f0 /UV f',tfifplalt <br />Final Test I I <br />Meter Release I I I <br />FINAL / / .3 /7i'%SULy1 <br />Notes, Remarks, Etc.'t <br />Contrrctor: