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M ECHANICAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hscby affm und6 panalty of pqjury that I m qmpt from thc CortreloB' Licarc kw for thc followirg rwn (Se.7031.5 <br />Buincs md Prcfeion Codc): Any City or County which rcquiro a pamit to onstruct, altc, improvq donolish or rcpair my <br />struclurc. Fior to its issmcc also rcquiu thc sppli@t for such pcnrit to 6tc s sigocd stalmal that hc or shc is lircGcd pwsd <br />to the provi3ioN of thc Cootretor's Licoscd Lrw (Chspta 9. Comocing with Sctio! 7000 of Division 3 of thc Bwine ud <br />Prcfeiom Codc) or that hc or shc b qmpt thac&om ed the brb for thc sllcgcd q@ption. Any violation of Scrbn 7031.5 by my <br />applimt for I pcmit subjels thc 8ppli@t to a civil pmlty of rct mrc th4 fivc hundrcd dollm (t500). <br />-1. <br />as owner ofthe property, or my employces with wages as their sole cornpensation, <br />intendod or offerd for sale (Scc.7044, Business and hofessions Code: The Contraclor's License Law does not apply to an owner of <br />the property who builds or improves thcrcorL and who does such work himself or herself or through his or her own employee, <br />provided that such improvanents are not intendod oroff€rod for sale. I[, howcver, the building or improvcment is rcld wilhin onc ]car <br />of compleliot\ the Orner Builder will have the burden of proving that he or she did not build or improve the propoty for the purposcof <br />sale). <br />_1, as owncr of thc prop€rty, am exclusively contraciing with licenscd contractors to construct the project (Sec. 7044, Buiness <br />and hof€ssbn Codc: The Contractor's Liccnse Law docs not apply to an owner of property who builds or improvcs thereon, <br />and who contracts for such projccts with a Conracto(s) liccnsed punrunt to the Contractor's Licensc l-aw). <br />-I <br />am exempt under Section-, B. & P.C. for this rcason. <br />Date: <br />S@EtsE8SSOMEENSAIIaN <br />DECI.ASAIION <br />I hocby aflirm undo pcnalty ofpa;jury onc ofthc following dclratiom: <br />-l <br />have md rvill mintah a Cqtificate of Cotlmt to SclfJNuc for workm' compqsalion. r povidcd for by Sdtion 3700 of thc <br />tzbor Code for thc pcfomcc ofthc wort for which thc pcrnit is i$ucd. <br />f/harc and *itl .aintain workm' comperustion imumcq I rcquircd by Sction 3700 of the tibor Codc. for thc psfomcc of <br />ihd work for which this pcmit is isod My work6' smpcosation irourme miq and policy numbcr re: <br />irn( ,-, tf rt nr t kt rn0 rt,{tY tr g -l t^o ule\f <br />Policy <br />_l 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 become subject to the workers' compensation laws of California, and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Codq I shall. forthwith comply with thosc provisions.. <br />WARNING: Failure to secure workers'compensation coverage is unlawful. and shall subject an anployer to criminal penalties and <br />compensation, damages as provided for thecivil fines up to one hundred thousand <br />Section 3076 of the labor Code, interest i <br />dollars ($100,000), in addition to thc cost of <br />and attorney's fees. <br />( <br />LICENSED CONTRACTOR <br />DECLARATION <br />I hercby affirm under penalty of perjury that I am licensed under p,rovision of Chapto 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 ,r^*, L - ) () License Numbcr: <br />W <br />I hcrcby alfum uda paaltyof pcjurythd thrc b 8 otrdnctbE ktrdirg egmy forthc psfomc of thcwrt br whichthir pqmit b <br />iscd (Se. 3097, Civ. C.). <br />Lender's Name: <br />Lender's Address: <br />APPLICAI\T DEC II\RATION <br />I ha6y affirm under petralty of pcrjury onc of the following declarations: <br />Dcmolition Pernrits-Asbcstos Notification Federal Rcaulations (Title 40, Part6) <br />-Required <br />Lctter of Notificaion <br />ffi;,"'*;ffi;ffi;ffi#*iil***with all City and County <br />and County to enter upon the <br />above mcntioned property for <br />Applicant or Agent <br />Pennitee name <br />purposes. <br />""", ng\l161 7t <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler ,r^.. <br />Furnace \D-/L-Ll fu^IU't) <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 Drver <br />Residential Ranee <br />Other <br />Hood <br />Type I Hood <br />Type II Hood <br />Grease Duct <br />Fire Damper <br />Openinqs <br />Installation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release <br />^a .-. <br />FINAL /0- /b-zl Lt;fr-Y,, <br />Notes, Remarks, Etc.\, <br />Owner:_ <br />",r",C2?l lbl X <br />lC/A t contrector:-