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MECHANICAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION <br />I hmby affm undc psuhy of Frjuy that I m Gxcmpt from thc Coilr.ctorc' Liccns taw for th€ followir€ rcmn (54.70.11.5 <br />Buincs and Profeion Codc): Any City or County which rcquirc a p6mit to @nstruct. alts. impovq danolish or cpair uy <br />structurq prior to its isswc, also requhc thc eplicmt for such pcflnit to 6lc a signcd samat that h€ or shc b licoscd puuut <br />to thc p(ovisioN of thc Cootsrctor's Lienrcd bw (Chaptq 9, Comcncing with Setion 700O of Division 3 of thc Busine ud <br />PrcfNioBCodc)orthathcorshciscxmptthsdromudthcbasisforthcdlc1cdcxmption. AnyviolaionofscrionT03l.5bysy <br />applicmt for a p€nnit subjcts thc applicet to . civil pmlty of not more thm five hundred dollil ($500). <br />-1. <br />as owncr ofthe propcrty. or my emplolees with wages as their sclle compensation. will do the work and the stnrctue is not <br />intended or offerd for sale (Scc.7044. Business and ho ssions Code: The Contractor's License [aw does not apply to an orvner of <br />the property who builds or improves thereon. and who does such work himself or herself or through his or her own employees. <br />provided that such improvanents are not intended or oflbrcd for sale. lf. howet/er. the hrilding or improvemeot is sold within one )rcar <br />of complaion, thc Ovmer Builder will have the hrrd€n of proving thd hc or shc did not build or improve the propoty for the purpose of <br />sale). <br />-1. <br />as o\\'ner of the propcrty. am exclusively contracting with licensed contractors to conslruct the project (Scc. 7044. Business <br />and Profession Code: The Contractor's Licensc Law does not apply to an ow'ner of property rvho builds or improves thercon. <br />and rvho contracts for such projects with a Contracto(s) licensed pursuant to the Conlractor's License Larv). <br />_l arn exempt under Section_. B. & P.C. for this reason. <br />Date:_ Owner:_ <br />WO RKER,S' COI}T PENSATION <br />DECLARATION <br />I hereby affrrrn under pcnalty of perjury one of the following declarations: <br />-l <br />have and rvill maintain a Certilicate of Consent to Self-lnsure fur rvorkers' conlpensation, as provided for by Section 3700 of the <br />Labor Code, for the performance of the work for w'hich the perrnit is issued. <br />-l <br />have and will rnaintain workers' cornpensation insurance. as required by Sc'ction 3700 of the Labor Code. for the performance of <br />the work for which this permit is issued. My workers' compensation insurance carrier and policy numbcr are: <br />Carrier: <br />Policv Numbcr: Exoires: <br />-l <br />certi& that in the performance of the work for which this perrnit is issued. I shall not ernploy any person in any manner <br />so as to become subject to the workers' compensation laws of California" and agree that if I should bccome subject to the <br />workers' compensation provisions of Seclion 3700 of the Labor Code. I shall. forthwilh comply rvith those provisions.. <br />WARNING: Failure to sccure workcrs' compensation coverage is unlawful. and shall subject an anployer to criminal perTralties and <br />civil fines up to one hun&ed thousand dollars ($100.000). in addition to the cost of compensation, damages as provided for the <br />Section 3076 of the Labor Code, interest and attorney's fees. <br />Annlircnl. <br />r rcrNsED coNTRACToR . <br />nr..t ArlATloN <br />I hereby allirm und€r penalty of pcrjury thd I am lic€osod 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 Class: License Number: <br />flota. <br />W <br />I tmby affm udc FuIy of Frjury thd th@ is a snstructioo koding sBCy for thc pafmcc of thc mrt for which thb p6nh b <br />isucd (Se. 3097. Civ. C.). <br />Lender's Name: <br />Lender's Address: <br />^ "rt ,c Nt "rc, <br />. *n <br />I hereby affirm under penalty of perjury one of the following declarations: <br />Dernolition Perrnits-Asbestos Notification Fedcral Regulations ('title 40. Parl6) <br />-Required <br />Letter of Notifrcation <br />-l <br />catiry that the fedcal rcgulaiom rcgarding rebctos rmoval ue not appliceblc to this projcct. <br />-l <br />cdiry that I havc r@d this application ed statc that the abovc infomation is conwt. I agr€ to comply with 8ll City and County <br />odimncG ud State Laws rclaling to building coGlruclion and hqcby authorirc reprGotativG of this City od County to 6tq upotr th€ <br />above m@tioncd prcpcriy for impetion purposs. <br />Applicant or Agent Signature:f-loto. <br />--Pennitee nzrme <br />Appliances t <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 ll Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />Insta!lation <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.