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M ECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNERBUILDERDEI,CARATION 'I hcby affm undo pcnalty of pc;jury thd I m qmpt from thc Contractoro' Licensc bw for thc following twtr (Se.703 1.5 <br />Buins and Proftssion Codc): Any City or County $'hich rcquirG E pqmit to coNtruct, alt6. improvc. danolish or rcpairpy <br />structuq Fior to its isumcc, also rcquiB thc applicilr for such pcmit to filc 8 sigrcd ststmot that hc or she b liccnscd pu*rt <br />to thc FovbioE of thc Contrelor'! Liensd Lsw (Chsptq 9. Comocing with Sction 7000 of Division 3 of the ksinsTod <br />PrcfcsioNCodc)orthathcorshcbqmptthscFomudthcbasisfortheallcgcd*mflion. AnyviolationofSetionT03l.Saymy <br />spplicutforapcmitsubjctsthc applicattoacivilpcnaltyofnotmorcthufivchundrcddollm($500). <br />a <br />-1. <br />8s owner of the property, or my employe'es with wages as their sole compersation. <br />intended or offered for sale (Sec.7044. Business and hofessions Code: The Conlractor's License Larv does not apply to an orvner of <br />thcprofgly whobuildsorimprovcthqoqudwhodoasuchmtkhimsclforho*lforthreughhisorhqomcmploy6, <br />providcd that such improvmls @ not intadcd orollqcd for gl€. If, ho$dc. thc hriHing or inprorrmcm is rcld wilhin onc 1a <br />ofcompletion. thc Ownq Builda will hav€ thc budm ofprcvinS thar he or shc did not tuild or itnprcvc thc prepqty for thc purpor of <br />slc). <br />-1, <br />a own6 of the yrcperty, an exclusivcly contracting with licqEed contractoE to consruct the S[ojct (Ss. 7044. Buine <br />md Prcf€sbn Code: The Contractor's Liccnse Law do6 not apply to o owns ofprcperty who builds or imprcvcs thq@n. <br />and who @nlBcts for such projets with a ContEcto(s) lic€ccd pu6@t lo th. Contmctor's Lictre taw). <br />-l <br />m excmpt unds Sstion-, B. & P.C. for this rcen. <br />Drte __ Ortr€r:_ _ <br />!4A8rc8S:.C0!4rnNArrAN <br />DECI.AEAIIO! <br />I hqcby alfm undo peoalty ofpcjury onc ofthe following dclaatiom: <br />-l <br />havc ud will mintain a Ccnificatc of Cowt to SclfJreurc for workds' conlpenstion, s trovidcd for by S6tion 3?00 of the <br />Labor Codc for thc pofonmcc ofthc rcrt for which the pqmit is isucd. <br />/l have and will maintain workers' compcuation imurancc. a requiled by Sation -l7OO of the Labor Codc. for thc pqfomucc of <br />/ tffc work for which lhis pftnit is isued My work6s' compcnsation insuracc cuia and policy numbo &c: <br />Policv Number: Exoires: <br />-l <br />cettify 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 worters'compensation laws of California. and agree that if I should become subject to thc <br />workers' compensation provisions of Section 3700 of the Labor Code. I shall. forthwith comply with those provisions.. <br />WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subject an anployer to criminal penalties and <br />civil fines up to one hundred thousand dollars ($100.000).in addition to the cost of damages as provided for the <br />Section 3076 tlrc interest and attorney's fees. <br />LIC EN S ED CON'I'RACTO R <br />DI.'CLARA'I'ION <br />I hoeby affirm under pmalty of perjury that I am licensod under provision of Chapter 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code, and my license is in full force and effect. <br />License <br />W <br />I hmby aflirm undo penahy of perjury thal thsc is a comtruciion lqding agmcy for thc psfomuce of the work for lvhich this p.rmit is <br />issucd (Ss. 3097. Civ. C.). <br />Leilder's Nanre: <br />Lender's Address: <br />APPLICA NT NT'C LAR.ATION <br />I hq'ebyaffirmunder penalty of perjury one of thc following declarations: <br />Dernolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />-Required <br />lrtter o f Notification <br />-l <br />coti$ that the federal regulations regarding asbestos removal are not applicablc to this projed. <br />-l <br />certify that I have read this application and state that the above information is correct. I agree to comply with all City and County <br />ordinances and State laws relating to building authorize representatives of this City and County to enter upon the <br />above nrentioned property for inspection <br />Applicant or Agert <br />Pennitce name <br />construction. and hereby <br />3 <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 />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residentia! Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openinqs <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Fina! Test <br />Meter Release <br />FINAL lo-11-.7,Lu 37" <br />Notes, Remarks, Etc <br />(.amer: <br />--/ <br />_ Contractor:_