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M EGHANIGAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILI'ER I'ET,CARATION <br />I h6cby alfm und6 poalty of pcrjury thar I m qmpt ftom thc Contr.cton' Licos lxw for thc following rtssn (Sc.7oll.s <br />Buin6s ard Prof6ion Codc): Ary City or Coutily which rcquic a pqEil to @E*ruc1 alta, imprcve danolbh or rcpair uy <br />ltructuqpriortoits isnmc,alsorcquimthc4lplicetforsuchparrittofrlcasigncdstdqmt thathcorshcbticEscd pwsril <br />ro thc Fovisiorc of thc Contrstor'3 Lienrd Lrw (Chapt6 9, Comming whh Setioa 7000 of Division 3 of thc BaiK ed <br />ProfcsionsCodc)orrh8thcorshcisqmptthac&ommdthcbasi!forthcallcfcdqanprion. Anyviohtimofs€{btr703l.5byey <br />@limt for a psmit $bjet3 OE ,pplicant to s civil pcElty of oot @rc thu fivc huodrcd dollars (t500). <br />_1, o ow of thc Fopcrty. or my cmptole with wag6 s thcir slc omposaioo, will do tlE wut ed tlE strrlrc is not <br />iotodcd or oltacd for ulc (Sa.7044. Buiae md Prcftssiou Codc: Thc ContEclor'r Licw law doc not 4ply to a om6 of <br />thc pmpqty who hilds or imporc thmn dd wbo doe sdr wr* himsclf or hmclf or thmugh his or ho om mploye. <br />prcvidcd thrr such impovumtr rc mr inadcd orofu for slc. tf, how, thc buildi4 or imFoEct b oH withio w la <br />of orryhion thc Orrm Buildc wil hErc thG hrd@ of provit8 thd hc or slE did rct huilC tr irprcrc thc popaty for thc trrpo*of <br />sak). <br />-1 <br />a omq of thc prcpqry, m qclwivcly mntracting with licqacd contrtrton to corutruct thc prcjet (Sc. 7044. BahB <br />ud Profusbo Co&l Thc Contnctor'! LicBc Law do6 not apply to m owna of prcpaty who builds or imprcv6 th6an, <br />ud who coDtrets for such prcj€1! with a Corxnclo(s) lbcracd pGuEtrl to thc Contncttr's Licre lrw). <br />-l <br />am exempt under for this <br />orr",-6-l'?}Ll <br />I hereby affrrm under penalty of perjury one of the following <br />_l have and will maintain a Certil'rcate of Consent to Sclf-lnsure for workers' conlpensation, as provided for by Section 3700 of the <br />Labor Code. for the p€rformance of the work for which the permit is issued. <br />_l have and rvill maintain workers' compensation insurancer as requird by Section 3700 of the tabor Code, for the performance of <br />the work for which this perrnit is issued. My workers' compensation insurance carrier and policy numh are: <br />Policy Number: ExPires: <br />_t certi& that in the performance of the work for which this permit is issued. I shall not employ any person in any manner <br />so as to bccomc subject to the workers'compcnsation laws of California. and agree that if I should becomc subject to the <br />work€rs' compensation provisions of Section 3700 of the Labor Code. I shall. forrhwith comply with thosc provisions.. <br />WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subject an onployer to criminal ponlties and <br />civil fines up to onc hundred thousand dollars ($100.000). in addition to the cost of comperuBtion.as provided for the <br />\ <br />LICF'NSEN CON'TRACTOR <br />DECI ARA'TION <br />I hereby affirrn under penalty of pojury that I am licensed under provision of Chapter 9 (cornmorcing with Se'ction 7000) of Division 3 <br />of the Business and Professions Code. and my license is in full force and effect. <br />lloto. <br />c(f NS'l't{u( "1'l0N l,!'NDl N(; AGllN('\', <br />I hmby affm uodq petralry of pcjury that th@ is a con$ruction hoding agacy for thc pcfoIrmce of the mrk br which this pamh b <br />issued (Sec. 3097. Civ. C.). <br />Lender's Name: <br />AITPLTCANT DFr.t ^ IU{TION <br />I hcndD, affirm und6 pcnalty of perjury onc of the following declarations: <br />Dernolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) <br />-Requ <br />ired l-ctter o f Notifi cation <br />> <br />with all City ad County <br />and County to exter upon the <br />above me'ntioned propcrty for <br />Applicant or Agent 4r <br />Pcnnitee name <br />r <br />>-.--2021 <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />Insulation <br />Smoke Detectors lnstalled <br />Rouqh 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 tl I D <br />FINAL I(2tR l'l.t )Nffi <br />Notes, Remarks, Etc.\l I IY { <br />L <br />License Class: License Number: <br />Contractor:_ <br />ell <br />lllt