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M ECHANICAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DET.CARATION <br />I hschy aflim undo pcmhy of pcrjury thd I m cxmpt ftom thc Contractors' Liccns lrw for thc following re+ (S6.m:'6 <br />Buins ad Prcfsion Codc): Atry City or County which rcquiru 8 pmh to @Gtruc1 altq. imprcvc dmolish or rcpair'my <br />structuc, prior to its isswca also rcguic thc rpplicet for such pqmit to filc I signcd ststmfit that hc or 3hc k licescd pl,Mt <br />to th€ FovisioN of thc Contrsctor'3 LiccnFd tlw (Chapt6 9. Comming with Setion 7fi)0 of Division 3 of thG Bwins md <br />Profsions Code ) or that hc or shc is qmpt thacfrom ild thc bsis for thc sllcgcd amFion. Any violation of Setion 703 I .5 by my <br />applicmt for a pcnnit subjffts thc lpplicet to s civil pmlty of not morc th8 fivc hundrcd dollus (S500). <br />-1. <br />os owner of the property. or my employees with wages as their sole compensation. will do the work and the structure is not <br />intended or offered for sale (Sec,7M4, Business and Professions Code: The Contractor's License Law does not apply to an owner of <br />the p,roperty who builds or improve tlreron. and who does such work himself or herself or through his or her own employecs. <br />provided that such improvancnts are not intcndcd or offered for sale. I[, howerrer. the building or improvcrnent is sold within one ]€ar <br />of complaion the Orvner Builder will have th€ hrden of poving tha he or shc did not build or improve the propcrt'y for the purposcof <br />sale). <br />-1. <br />8!r owrrer of the property, am cxclusively conrading with licerscd contraclom to construct the projecr (Sec. 7044, Business <br />and hoftssion Code: The Contrac-tor's License Law does not apply to an owncr of property who builds or improves thereon, <br />and who contracts for such projects with a Contracto(s) ticeased punusnt to the Contractor's License l-aw). <br />-l <br />am exempt under Section-, B. & P.C. for this reason. <br />Date:I ls,rretr.. <br />WORKERS' COMPENSAI'ION <br />DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: <br />-l <br />have and rvill maintain a Cerrificate of Consent to Self-lnsure for rvorkers' conrpensation, as provided for by Section 3700 of the <br />Labor Code. for the performance of the rvork for which the perrnit is issued. <br />-l <br />have and will maintain workers' comperuation insurance. as required by Section 3700 of the Labor Code. for the performance of <br />the work for which this permit is issued. My workers' compensation insurancc carrier and policy number are: <br />Carrier: <br />Policv Numbcr: Exoires: <br />-l <br />certi& that in the performance of the work for which this p,ermit is issued" I shall not employ any person in any manner <br />so as to bccome subject to the workers' compensation laws of California, and agree that if I should become subject to thc <br />workers' compcnsation provisions of Section 3700 of the l-abor Code I shall. forthwith comply wilh those provisions.. <br />WARNING: Failure to secure workers' compcnsation coverage is unlawful, and shall subject an employcr to criminal ponhies and <br />cMl fines up to one hundred thousand dollan ($100,000), in addition to the cost of compensation, damagcs all provided for the <br />Section 3076 of the l-abor Code. interest and attorney's fees. <br />. <br />A nrrlinonl. <br />LICF'NSED CONT&{CTOR 'DECI AIL{TION <br />I hereby aflirm under perialty of pcrjury that I am licsrscd under povision of Chapter 9 (commencing with Section 7000) ofbivision 3 <br />of the Business and Professions Code, and my licerue is in full force and effect. <br />License Nurnber: <br />W <br />I hcrtby allim unda paaty of pajury tha thft b a @trdrucliotr koditrg ag6cy for thc pafolffi of the mrt 6r which this pamit b <br />i$ucd (Se. 309?, Civ. C.). <br />Lender's Name: <br />Lender's Address: <br />,plrcA^,, nFC, RArrN <br />I herelry aflirm under penalty of perjury one of the following declarations: <br />Dernolition Perrnits-Asbestos Notification Federal Regulations (Title 40, Part6) <br />-Required <br />Letter of Notification <br />-l <br />cqtify thd thc fcdcal rcjulariore rcgardiag sbctos moval rc not applicablc to this proj6t. <br />-l <br />cdiry thd I havc Ed this application ad statc tha the abovc infomation is cor({. I agre to omply with all City and County <br />ordinmcs ad State [:m rclairy to huilding corotrucrio[ atd hftby authoria rcF6antative of this City rd County to otq upon tlrc <br />abovc m@tioncd prcFrly for irpetion purpos. <br />f,)dc: r -Applicut or Agot Signaluc:_ <br />Permitce niune <br />.ApplAnceb <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 Installed <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 <br />Notes, Remarks, Etc. <br />.t^,o <br />I <br />a <br />l)nte:Contractor: