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M ECHANICAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BI'ILDER DELCARATION <br />I hcrcby sllirm unds pcoslty of pcrjury thst I m excmpt ftom th€ Contrsc,loE' Lktn$ lrw for thc following msn (Sec.7031,5 <br />Business ild Prcfcssion Codc): Any City or County vhbh requircs 8 pemit to onstrct, altcr, improw, demlish or Eprir my <br />suuctrc, prior to its issure, alrc rquircs thc spplisl for such permit to file r signed slrlcmnt lhat hc or slE is liccnrcd pususnt <br />to thc prcvisioos of the Contrctor's Llrcoscd L:w (Chrptcr 9, Commrcing with Setion 7fiD of Division 3 of thc Busircss ud <br />Profcssions Codc) or thst hc or slrc is cxcmpt thcrcfrom 8rd the bssis for thc alhgcd cxemplion. Any viohlion of Setion 7031.5 by any <br />applicsnt for a lrcrmit subjccts the applicant to 8 civil pemhy of not mrc thatr live hundred dollus (5500). <br />_1. as owncr of thc property. or my cmployees with wagcs as their solc compcnsalion, will do the work and the strLrdure Ls not <br />intcnded or offered for salc (Sec.7044, Busincss and Professions Code: Thc C-ontractor's License Ilw does not apply to an owner of <br />the property who builds or improves thereon, and who does such work himself or hcrsclf or through hi.s or her own employces. <br />providcd that such improvcnrnts are rKrt interdcd or offercd for sale. lf. howerrcr. thc building or inproverrcnt is soh within one )tar <br />of conplction thc Owner Buildcr will harc the burdcn of proving that hc or stre did not buiH or inqnove the property for the purpsc of <br />salc). <br />_1. as owner of thc propcrty, am cxclusivcly contracting with licenscd contractors to construct the projcct (Sec. 7W. Busirrcss <br />and Profcssirn Code: Thc Contractor's Licensc Law docs not apply lo an owner of property who builds or improvcs thereon, <br />and who contracts for such projccts with a Contractor(s) licensed pursuant to thc Contraclor's License Law). <br />-l <br />amcxempt under Section-, B. & P.C. for this reason. <br />I)ate: <br />WORK I.' RS' COI\I PENSA'I'ION <br />DECLARATION <br />I hcrcby affirrn undcr pcnalty of pcrjury onc of thc following dcclarations: <br />-l <br />havc and will nuintain a Certifrcatc of Conscnt to Self-lnsurc for workers' c-ompensation, as provided for by Section 3700 of the <br />I-abor Code, for the performance of the work for which the pcrmit is issucd. <br />-l <br />have and will maintain workers' compensation insurancc, as rcquircd by Scction 3700 of thc [,abor Code, for thc performance of <br />thc work for which this pcrmit is iszucd. My workcrs' compcnsation insurancc carrier ard policy numbcr arc: <br />c,,i",, TLuIIJ Ctf{ ftUlE f|\i:w <br />t ltCPolicyl/I I <br />-l <br />certify that in the performance of the work for which this permit is lssucd. I shall not employ any perso.l uf any manncr <br />so as to bcconrc subject to thc workers'compensation laws of California, and agrcre that if I should bcconr subject to the <br />workers' comyrcnsation provisions of Section 3700 of the Labor Code. I shall, forthwith comply wilh those provisions.. <br />WARNING: Failure to secure workers'compensation coverage is unlawful, and shall subject an employer to criminal penalties and <br />civil fines up to one hundrcd thousand dollars ($100,00t1), in addition to thc cost of compensation, damages as providcd for the <br />fccs. <br />I)I.:CLARA'I'ION <br />I hcreby affrm under penalty of perjury that I am licensed under provision of Chapter 9 (comnrcncing with Section 7000) of Division 3 <br />of the Busincss and Professions Code, and my license is in full force andrffcct. <br />,bLiccnscNumber: <br />I hcrcby sffrm under Jrcnally of lrcrjury that thcrc is a @nstruclion hnding agency for thc [Erformrcc of thc work for which this lnmit is <br />issucd (Scc. 3097. Civ. C.). <br />kndcr's Namcl <br />Lrndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcrcby aflirrrr undcr pcnalty of perjury onc of lhc lirllowing dcclarations: <br />Dctnolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) <br />_Rcquircd Irttcr of Notification <br />_l ccrtify that the fedcral regulations regarding asbestos removal are not applicable to this project. <br />_l ccrtify that I havc rcad this application and statc that thc atnve information i' ordinanccs and State laws rclating to building construction. and hereby authorize <br />is correct. I agree to comply wilh all City and County <br />representativcs of this City and County to enter ugnn the <br />abovc mcntioncd proFrcrty for inspection <br />Applicanl or Agcnt <br />Pcrnritcc namc <br />o*", o tr/ oqhl <br />Appliances <br />l\Ietal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />lt/isc. Equipment <br />Duct Work <br />Pre-lnsulation I Itk 7(DLITVY 7 <br />lnsulation <br />Smoke Detectors lnstalled <br />Rough Ductwork <br />Vents <br />Toilet Room I Clothes Drver <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Tvpe ll Hood <br />Grease Duct <br />Fire Damper <br />Openinqs <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid I <br />Above T-Bar L '\fr -?r\D**n <br />I <br />Rouqh Mech. <br />Final Test <br />Meter Release (rl o, <br />FINAL ff\ \q \)\\fl[a ) <br />Notes, Remarks, Etc.\\ <br />Owner: <br />Date:t)3/3L <br />--l, <br />={n cte fn Z <br />) <br />I <br />(h <br />-t