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M ECHAN ICAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUTLDER DEI,CARATION <br />I hmB aftm ud6 parlty of pajury that I m cxmpt iom thc CrntrrctoE' Licm l:w for lhe followiag rcn (Se.7031.5 <br />Buine ard Prcfeion Code): Atry City or Couty which raquirG a Fmit to strlrucl, altq, improvc dsrcliEh or Epsir my <br />stluduq Fbr to its ismcq alm rcquirc thc applimt for such Frnit to 6lc 8 ligocd stdaat tha hc or shc b ticqscd pwant <br />to thc provbios of thc Contretor's Liccnscd ljw (C1Efl6 9. Comociag witb Sction 7000 of Division 3 of thc BuirB ed <br />Prcfsions Codc) or that hc or shc b qmpt thEcfrom md thc bosis for thc sllcgcd qmplioo Aoy violntion of Sctbn 7031.5 by uy <br />applicant for a pannit subjcts thc ap,plimt to a civil p@ltyof rot mrc thfi fivc hundrcd dollm (5500). <br />-1. <br />as owner of the property, or my emplo),ees with wages as their sole compcnsation, will do the work and the stnrture is not <br />intendod or offerod for sale (Sec.7044, Business and hofessiors Code: The Contractor's Liccnsc law does not apply to an owner of <br />the property who builds or improvcs thcreon, and who docs such wort himself or hcrsclf or through his or her own cmployecs, <br />provided that such improvanents arc not intendcd or ofFered for sale. l[, howwer. the building or improvernent is rcld wilhin onc ]car <br />of complaiorL the Orvner Builder will have the hrdcn of proving thd he or she did not hrild or improve the prropoty for the purposcof <br />sale). <br />-1, <br />8s owner ofthe prop€rty, am exclusively contracting with licenscd contraclon to corstruct the project (Sec. 7044. Brsiness <br />and Prcf€ssbn Code: The Contractor's License Law does not apply to an owncr of property who builds or improvcs thereon, <br />and who contracts for such projeds with a Contracto(s) licenscd pursuant to the Contraclor's License l-aw). <br />-l <br />arn cxempt under Section-, B. & P.C. forthis reason. <br />Drte: <br />WORKERS' COMPENSATION <br />DECI,ARATTON <br />I hereby aflirm under paralty of perjury one of the following declarations: <br />-l <br />havc and will maintain a Cenificate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of the <br />l-abor Code, for the performance of the work for which the perrnit is issued. <br />_l have and will maintain workers' compensation insurance. as requircd by Section 3700 of thc l-abor Code, for the performance of <br />the work for which this permit is issued My workers' compensalion insurancc carrier and policy number are: <br />PolicyNumber: Erpires: <br />_l ccrtiff that in the performance of the work for which this permit is issucd. I shall not employ any person in any manner <br />so as to become subject to the workers' comperuation laws of California and agree that if I should bccome subject to the <br />wor'k€rs' compensation provisions of Section 3700 of the l-abor Code I shall. forthwilh comply with those provisions..L <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 cosl of compensation. damages as provided for thc <br />Section 3076 of the Labor Code, interest and attorney's fees. <br />DECI.,ARATION <br />I hereby affrm under penalty of perjury that I am licenscd undcr provision of Chapter 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code, and my licensc is in full forcc and effect. <br />loJ 04(lLicenseNumber: <br />ort.,,Q-t I -9, &rt <br />(:ONSI'RLIC'IION T,EN DI N(;,\G I'N('\' <br />I hcby affm uda pcrElty of pgjury that tb@ is r @nstruclion krding agocy for thc pqfotmcc of thc w* for which thb pqni b <br />Civ. C.). <br />Lcnder's Addrcss: <br />APPLICANT DEC LAITATION <br />I hcret y affinn under penalty of perjury one of the following declarations: <br />Dernolition Pcrmits-Asbestos Notification Federal Regulations ('title 40. Part6) <br />_Required Letter of Notification <br />-l <br />ceitift that the federal regulations regarding asbestos removalare not applicable to this project. <br />_t cdiry thar I havc rod this applicalion and statc that th€ abovc information is corcct. I agrE to comply with all City aod County <br />ordinanca md Statc [aw rclaring to building constructioG md hqcby suthorirc rcprsntativG of this City md Cou[ty to atq upoo thc <br />above mentioned property for <br />Applicant or Agent <br />Pennitec narne <br />o","' J-g t'-99,1 <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 Drver <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />lnstallation <br />F. D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech.q,L;'71 p-uZ <br />Final Test <br />Meter Release <br />F!NAL c1 _?,z\(?s-ti A € OA3 "2,,1 , <br />Notes, Remarks, Etc. <br />Carrier: <br />oarc,&-g f -bA <br />conrractor,k dtrb <br />Lcnder's Name: