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M ECHANICAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUTLDER DELCARATION <br />I hccby aflm undo poalty of perjury that I m qmpt 6om thc Contractore' Liceroe Law for the following Iwn (Sc.7031.5 <br />Busin* and Profsion Codc): Any City or County which rcquirc a pcrnit to snstruct. altq, imprcvc. darclish or rcpoir my <br />strucluc, Fior to its isumcc. also rcquiG thc applicmt for such pcrmit to file s sigDcd stalm@t lhd hc or slE b licoEcd plmatrt <br />to thc provisiom of thc Conurctor'r Liccnscd l:w (Chaptq 9. Commcncing with Sction 7000 of Division 3 of thc Busine md <br />Prcfssions Codc) or that h€ or shc is qmpt th@from ild thc bais for the allcgcd cxmFion. Aoy violstion of Strtbn 703 I .5 by my <br />applicmtfor8pcmitsubjctsthc applicsnttoacivilpmltyofnotmorethilfivehundrcddollm($500). <br />, <br />-1. <br />as owner of the propcrty. or my employees with wages as their sole compcnsation. will do thc work and thc snrctrne is not <br />intended or offered for sale (Se.7044. Business and hofessions Code: The Contractor's Licqrse Law does not apply to an owner of <br />the property who builds or improves th€r@n. and who does such wort himself or hcrself or through his or her own employees. <br />provided that such improvoncnts are not intendcd or offered for sale. l[, howwer. ttrc building or improvsncnt is sold within one ],tar <br />of complaiorL the Oumer Builder will have the hrdcn of proving thd hc or she did not build or improve the propcrty for the purposeof <br />sale). <br />-1. <br />as owner of the prop€rty. am exclusively contracting with licensed contractors to construct the project (Sec. 7044. Btsiness <br />and Proftssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thcr@n. <br />and who contracts for such projects with a Contraclo(s) licersed pursuant to the Contractor's License Larv). <br />_l arn exempt under B. & P.C. for this reason. <br />Date:_( )rr ner: <br />WORKERS' COIITPENSATION <br />DECLARATION <br />I hereby affirm under poralty of perjury one of the follorving declarations: <br />_l have and will maintain a Certificate of Conscnt to Self-lnsure for workers' contpensation, as povidcd for by Section 3700 of the <br />I-abor Code. for the perfonnance of the work for which the pennit is issued. <br />X <br />the <br />have and will maintain workers' comp€nsation insurance. as reauired by Section 3700 of the Labor Code, for the pcrfonnance of <br />work flor which thispermit is issued. My <br />l{as44?e <br />workers' compensation insurance carrier and policy number re: <br />carrier: furt^l /a SUlAaa ? Cj./wt /t't y <br />WrZ 6T7Z oL/Policy <br />t <br />_l certify that in the perforrnance of the rvork for rvhich this perrnit is issued. I shall not ernploy any person in any trlirret <br />so as to be,come subject to the workers' compensation larvs of California. and agree that if I should becotne subject to the <br />rvorkers' colnpensation provisions of Section 3700 of the Labor Code. I shall. ftrrrhu'ith cornply rvith those provisions.. <br />{ <br />WARNING: Failure to scrure workers' compensation coveragle is unlawful. and shall subject an to <br />l <br />and <br />civil fines up to one hundred thousand dollars ($100,000). <br />Section 3076 of the Labor Code. interest and attorney's fees. <br />in the <br />Dnte:/t/*rtr-r <br />I hereby aflirm under pcnalty of perjury that I am licemed 9 (commencing u'ith Section 7000) of Division 3 <br />of the Business and Professions Code. and my license is in full force and effect. <br />CLO 9 ao 7License <br />Drte:g/ zt /zot- ( <br />I hereby alTirm under pcnalty of perjury that there a aSency the performance of thc work for u'hich this permit b <br />issued (Sec. 3097. Civ. C.). <br />Lender's Name: <br />Lender's Address: <br />,rt tcANr'"rc <br />I herdry aflinn under penalty of perjury one of the follorving declarations: <br />Dernolition Perrnits-Asbestos Notification Federal Regulations ('I'itle 40. Pan6) <br />-Required <br />Letter of Notification <br />-l <br />certip that the federal regulations regarding asbestos removal are not applicable to this project. <br />_l certi& that I have read this information <br />ordinances and State l-arvs relating to <br />above mentioned property for <br />Applicant or Agent <br />Permitee nilne <br />that <br />(z/ZAL <br />the <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work /l tt .-n <br />Pre-lnsulation TiltN wm{f,a t4g <br />lnsulation I <br />Smoke Detectors lnstalled <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type !l Hood <br />Grease Duct <br />Fire Damper <br />Openinqs <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid //,r'.a <br />Above T-Bar 7/trll/?v?e "mf7I <br />Rough Mech. <br />Final Test <br />Meter Release //Ir <br />FINAL r0//*72r ItP:Y,Lh <br />Notes, Remarks, Etc.I <br />pro\ <br />License <br />Contrnctor:a <br />purposes. <br />t <br />cXwt <br />-T <br />l/L, - , <br />&K