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M ECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE !D/SIG.COMMENTS OIVNER BUII,DER DEI,CARATION <br />I hcrcby ollirm undcr pcn{lty (rf pcrjury lhul | {m cxcmpl fronr thc Cdilrnck)rs' Liccnsc lf,rw for rhc lblk)wing rcason (Scc./tlJ3l.5 <br />llusitrcss n[l Profcssk)n Codc): Any C'ity or Cr)utrty which rcquircs a Jrrtrril to corslrucl. altcl iuprovc. dcnnlish or rcplir any <br />slructurc. prtrr to its issuancc. also rcquircs the applicant li)r such lErnril kr l'ilc l signcd slulctrrcnl lhrl hc or shc is liccnrcd putsuant <br />to lhc provisk)ns of lhc Contrnck['s Liccnscd hs (Chtptcr 9. Cornrrcncing wilh Sccli(nl 7000 of Division 3 of lhc Busirtcss anrl <br />ProlcssionsCodc)orthathcorshciscxcmpllhcrcfromnndthchasislorlhcallcgcdcxcnplhn. AnyviohliorolScclhnT0.ll.5byany <br />upplicrntlbrrJ,crmitsubjcclslhc applicanltorcivilpcililhyofnotn()rclhanlivchundrcddollilrs(S500). <br />_1. as owncr of lhc prcJf,rty. (,r nry cnrpk)yccs with wrgcs as thcir *)lc conrpcnsalion. willil) llrc work ilrd thc stMlurc is fiil <br />iltclxlcd orollcrslforelc(S(.T044.BusincssandPnrlcssionsC(dc:'lhc('ililr0ctrr'sl-iccnrl:wdr)csnolapplyloilnosncrof <br />lhcpmFny *hrbuildsorirqrrrrcslhcBln.an(lwhod(E\suchuorkhitrrsclforhcrsclforllrrouShhisorhcrowncmployccs. <br />providcd that such imp()vcmnts arc fril iilcndcd or ofllrc(l tif srlc. ll. howcvcr. thc huildiilg or irrprrvctrrnl is srld within onc ]rtr <br />ofcoNphti(nt thc Owncr Buiklcr will hrrc thc hurdcn of prrving thd hc or shc (lkl not buikl or hr[rovc lhc pn,Fdy for tlrc purfxrs of <br />vrh). <br />-1. <br />as owner of thc propcrty. am cxclusively contracting with licensed conlraclors lo conslruct the pmject (Sec. 7W, Busincss <br />and hrrfesshn Codc: The Contractor's Liccnse Law docs not spply to nn owncr of prolrcrty who builds or improves thereon. <br />and who contracts for such projccts with a Contracto(s) liccnscd pursuant to the Contractor's License Law). <br />-l <br />amcxempt under Seclion-. B. & P.C. forthis reason. <br />I)llt: ()rrlttr. <br />WORKF'RS' COTVIPENSATION <br />DI'-CLARATI,N <br />I hcrcby affirm undcr penahy of Jrrjury one of lhe following dcclarations: <br />-l <br />have ald will maintain a Certil-rcatc of Conscnt to Self-lnsure for workcrs' compcnsalion. as provided for by Section 3700 of the <br />L-abor Code. for the performsnce of the work for which thc Jrermit is issued. <br />-l <br />have and will maintain workcrs' compcnsation insurancc. as requircd by Scction 3700 of thc Lahor Code. for the pcrfornunce of <br />thc work for which this pcrmit is iszued. My workcrs' conU)ensation insurancc ciurier and plicy numhr ef,c: <br />Policy <br />_l certily that in the Jrcrformancc of thc work for which this Jrcrmit is issucd. I shall nol employ any lrcrson in any manncr <br />so as lo trc-conrc subjcct to the workers'comfrnsation laws of Californin. and agrcc thal if I should bccomc suhjcct to thc <br />workcrs' compcnsation provisions of Section 3700 of thc l-.abor Codc. I shall. forthwith cornply with thosc provisions.. <br />WARNING: Failurc to sc.cure workers'comgrcnsation covcrage is unlawful. and shall subjcct sn employer to crinrinal penaltics and <br />civil fincs up to onc hundrcd thousand dollars ($l0o,finl. in addition lo thc cost of compcnsation. domrgcs as providcd for the <br />Scction 3076 of thc Latnr Code, interest and attorncy's fees. <br />,\pplit'trtl: <br />LICENSED CON'IRAC'I'OR <br />DFCLAIIATION <br />I hcrcby alf irnr ulrdcr pcnalty of pcrjury lhat I arn liccnscd untlcr provisiott of Chlplcr 9 (cottuncncing u'ith ,Scction 7(Xm) ol'Division J <br />o[ thc I]usirrcss and Prol'cssiorrs Codc. arxl nty liccnsc is irr lirll lirrcc anrlcl'l'cct. <br />License Class: Liccnse Numbcr: <br />Dale:_('onlrttclor: <br />CONSTN.UCTTON LENDINC AGI:NCY <br />I hcrcby amrm undcr lrcnillty of Frjury thdt lhcrc is c conslruclion lcnding ngcncy lor lhc ltrli)nurrrcc of lhc sork titr which lhis firmil is <br />issucd (Scc. -109?. Civ. C. ). <br />Lcrtdcr's Narttc: <br />l'cndcr's Addrcss: <br />,*LICAN' ITECLAR , <br />I hcrcby aflinn undcr pcnalty of pcrjury onc ol'thc following dcclurations: <br />Dcmolition Pcrmits-Asbcstos Notilication Fcdcral Regulations ('Iitle 40. Part6) <br />-Rc<luircd <br />[rttcr of Notification <br />_l ccrtify that the fcdcral rcgulations rcgarding asbcstos rcrxrvalare nol upplicablc to this projcct. <br />_l certify thst I h8vc Esd lhis application ad state lhat thc abovc informlkrn is coret. I agrc lo @mply wilh 8ll Citysnd County <br />ordin8res snd Statc kws Elating lo building construction. ad hcrcby authorizc Eprcsnlativcs of lhis City ud Counly to enlcr upon lhc <br />otnve mntkrrcd prcperty for ioslrcdion putnss. <br />Applicant or Agcnt Sigrralurc: <br />Pcnnilcc nanrc (prinl ):_- <br />[)ltc: <br />Appliances <br />[Vletal 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 />Rouqh Ductwork <br />Vents <br />Toilet Room I Clothes Dryer <br />Residential Ranqe <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 l/^l ) <br />FINAL t2ltt /7 r wilrt ME\ <br />Notes, Remarks, Etc.I <br />_Expircs: <br />\