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APPROVALS DATE ID/SIG.COMMENTS <br />Appliances <br />Metal Fire Place <br />Evap Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />Insulation <br />Smoke Detectors Installed <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type II Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />Installation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release <br />FINAL h]r/ LILEn lo-[j2t a) v\Qq(ru 7€12yttT <br />I hereby affirm under penalty of perjury that I am exempt form the Contractors' License l-aw for the following reason (sec.703l .5 BSin.rt <br />md Profssion Codc): Any Cily or County which rcquim a pcmir to comtrucl, alts. imprcvc. dcmolish or rcpsir my structuc. prior to its <br />issuncc. also rcquirc thc rpplicsnt for such pcmit to Iilc a signcd statcmcnt thrt hc or shc is liccrocd pmuut to thc prcvisioG of thc <br />Conlractor'3 LiccBcd Lsw (Chspts 9, Commcncing *ith S@tion 70OO ofDivbion ! ofrhc Buriner and Profarioro Codc) ol'that hc or <br />shc is cxcmpt th@from rnd thc b6i! for thc sllcgcd cxcmflion .Any violatiou of Sectioo 7031.5 by my spplic8il for r pcmit subjcct! sE <br />applicsnt to 8 civil pcmlty of not mrc rhu tivc hundrcd dollm ($500). <br />_1. r ownr of thc prcpcrty. or my cmployc with wag* r thcir soh comDNtioo, will do thc wott md thc struclre is not inhdcd <br />or offocd for rlc ( Se.7oil4, Bain63 tnd Profcssions Codc: Thc Contnctor'r Liccrec Lr* do6 not rpply to m oma of thc prcpcny <br />who builds or imprcvc thc@o. std who d6 s$h wort himclf or hcrclf or thrcugh his or hcr owtr cmploy€, prcvidcd th8t such <br />imprcvmcnts e rct iilcndcd or off6(t for s!lc. If, how€E thc buildiog or imprcvmcnt is rcld within orc yc of complaio[ thc <br />olrm-Builda will havc thc bwdcn of prcving thlt hc or shc lot build or imprcvc for thc purpo$ of slc). <br />_1, I owocr of thc propcrly. m excluivcly cotrtncting with liccBcd contr&toF to oBtruct ttr pIojct ( Sa. 7044. Bwinss md <br />Prof!$ion Codcr ThG Contrrclor's Liccnsc lrw do6 not spply to m owffi of prcpaty who builds or improvg thc@n . aod who <br />@nt6ct! fo. such proje$ with a Contncto(3) liccnlcd puBunt to thc Contnclor's LiccN lrw). <br />_l arn excmpt under Section .8. & P.C. for this reason. <br />Date: Orvner: <br />WORKDRS COMPENSATION DECLARA'I'ION <br />I hcrcby aflirm under pcnalty ofpcrjury one ofth€ following declarations: <br />I havc and will mainlain a Ccrtificatc ofConscnt to Self-lnsure for workers' conrpcnstion. as provided for by Section 3700 ofthe <br />trbor (bdc. for lhc perfornraocc oflhc work for which the pcrmit is issucd, <br />_l havc and will mintain worken' ompcmtion insuranca r required by Sedion 3700 of the Lrbor Code. for thc pcrfornuncc of thc <br />work for which thfu pcrmit i3 isucd. My workcrs' ompcnstion insuran@ €ricr rnd policy oumbcr rc: <br />Policy Number: Exphes: <br />(This section n. 001 or less) <br />_l certify that <br />bccame subject <br />in the performance of the work for which this permit <br />of California, and <br />is issued. I shall not in any manner so as to <br />to the workers' compensstion laws agree that if the workers' <br />compensation provisions of Section 3700 of the labor Code. I shall.those provisions. <br />WARNING: Failure to secure workers' compensation is unlawful, and shall subject an employer to criminal penalties and civil <br />fioa up to orc hundrcd thoMd dolhB ($100.000),in addition to thc cost of compffiaioo. damges r providcd for thc Setion 3076 of <br />thc lrbor Codc, intcrBt snd rttorrcy's fc. <br />W <br />I hcrcby sffim und6 pcmlty ofpajury thrt I m licenrd undr prcvision ofChapta 9 (commcncing with Scction 7000) ofDivision 3 of <br />thc Buincss and Professio6 Codc, End my liccBc h in full forcc and cfftrt. <br />License Nurnber za <br />Date:-/ <br />('ONS'TRI.'C'TION LENDING AGEN('Y <br />I hcreby aflirm uodcr pcnally ofpcrjury lhal lhere is a construclion lcnding agency for lhc pcrfonnance ofthc work for which lhis pcrnrit is <br />issucd (Scc..1097. ('iv. ('.). <br />Lender's Name <br />Lender's Address: <br />APPLICANT'S DECLARATION <br />Demolition Permits-Asbestos Notification Federal Regulations (Title 40. Part 6) <br />_ Required l-ctter of Notification <br />_l certify that the fcderal regulations regarding asbestos removal are not applicable to this project. <br />_ I certiff that I have read this application and state the above information is correa. I agree to comply with all City and County <br />ordinances and State l-arvs relating to and hereby authorize representatives of this City and County to enter upon the <br />above mentioned property <br />Applicant or agent <br />Pennittce narne ( print): <br />/z- /u^ / <br />M ECHANICAL.INSPECTOR RECORD <br />4ol 3666? <br />o^tr, /2 -/t-// <br />lrr <br />Date :