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M ECHAN ICAL.I NSPECTOR REGORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI.CARATION <br />I hcby affm undo poalty of pqjury thst I m cx€mpt &om thc ContBcloB' Liccre Law for th€ followitrg wn (Se.7031.5 <br />BNin6s aDd Profeion Codc): Any City or County which rrquirc a pcmit to orotruct! altc, improvq danolish or icpair uy <br />structuc, prior to its i$lmc, also rcquiE thG applicmt for such pcmit to filc I signcd stat@mt that hc or shc is lictrscd pmumt <br />to thc FovisioB of thc Contretor's Liccnscd Lrw (Chr9t6 9, Comacing with Sction 7000 of Divisioo 3 of thc Buind md <br />Prcf*sioru Codc) or that hc or she is cxcmpt thccfrom ed thc bais for the alleAcd amdio[ Any viokrlion of Sctbn 7031.5 by my <br />applicut for a pqrnir subj€t! thc spplicmt to s civil pmlty of not mrc thfi fivc hundrcd dollm ($500). <br />-1, <br />as own€r ofthe propsrty, or my cmplol,ee with wages as their sole compensation. will do t!rc wort ard thc stnrctune is not <br />intcnd€d or offcrcd for sale (Sc.7044, Brsiness and Pr,ofessions Codq The Contractor's Licensc l-aw does not apply to an owner of <br />the property who builds or improv* theron, and who does such work himself or herself or through his or hcr own employees, <br />providcd that such improvemcnts are not intended oroftrod for sale. If. howarer, ttrc hlilding or Lnproverncot is rcld within one )Gn <br />ofcomplaion, the Orrner Buildcr will have thc burden ofpnoving tha hc or shc did not build or improve thc propcty forthc purposcof <br />sale). <br />-1, <br />as own€r of the property, am exclusively contracting with licerucd contractors to construct thc project (Sec. 7044, Brsiness <br />and hofissbn Code: The Contractor's Licclse kw does not apply to an owner of propcrty who builds or improves thereon, <br />and who contracts for such projeds with a Contracto(s) liceosod pursuant to the Contrac{or's License l-aw). <br />-l <br />am exempt undcr Section-, B. & P.C. for this reason. <br />ft-. ^. <br />WORKERS' COMPENSATION <br />DECI.ARATION <br />I hereby affrm under pcnalty of perjury one of the following declarations: <br />-l <br />have and will maintain a Ccrtificate of Consent to Self:lnsurc for workcrs' compensation, as provided for by Section 3700 of the <br />Labor Codc for the pcrformance of thc work for which the pcrmit is issued. <br />-l <br />have and will maintain workers' compcnsation insurance, as required by Section 3700 of the l-abor Code, for thc pcrformancc of <br />the work for which this perrrit is issued. My workers' compcnsation insurance carrier ad policy number are: <br />Gre.n<-oa.\ (Ar".4q. lV <br />poricy N" tu, K€,Lil oZZ 62:26 Expires: {'^O| -2-> <br />-l <br />ccrti& that in the performancc of the work for which this permit is issued I shall not employ any pcrson in any maoncr <br />so as to become subject to the workers' comperuation laws of Californiq and agree that if I should become subject to the <br />workers' compansation provisions of Section 3700 of the l-abor Codc, I strall forthwith comply with thosc provisioru.. <br />WARNING: Failure to secure workers' compcosation coveragc is unlawful, and shall subject an cmployer to criminsl peaalties and <br />civil fines up to onc hundred thousand dollars ($100,000), <br />Section 3076 of the Labor Code interest and attornry's fees. <br />in addition to the cost of damagcs as provided for thc <br />05 €2- <br />LICENSED CONTRACTOR <br />DECLARATION <br />I hereby affrrm under penalty of perjury that I am liccnsed undcr provision of Chapter 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code. and my liccnse is in full force and effect. <br />G>o 2(,cLicense <br />^.... I -- el (-e_t <br />CONSTRUCTION LENDING AGENCY <br />there is a construction landing ageocy for the pcrfonnance of the work for which this perrnit isI hereby affuur under paultyof perjurythat <br />issued (Sec. 3097, Civ. C.). <br />I-cnder's Name: <br />Lelder's Ad&ess: <br />A."LIC NT DECLARATI* <br />I ho,*y affirm under penalty of perjury one of the following declarations: <br />Demolition Permits-Asbestos Notification Foderal Regulations (Title 40. Part6) <br />-Required <br />l-ctter of Notification <br />-l <br />certiff that the federal regulations regarding asbestos removal are not applicable to this project. <br />-l <br />certi$r that I have read this application and state that the above information with all City and County <br />and County to entcr upon thcordinances and State Laws relating to building constructioru urd <br />above mentioned property for inspection purposes. <br />Applicant or Agent <br />Pennitee name €UI *r". lo,-ti --1v) <br />Appliances <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 />Openinqs <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release <br />FINAL I l-ao -2 r e{t <br />Notes, Remarks, Etc.