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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hftby afftm und6 panalty of prjury thd I m qmpt ftom thc Contrrtos' LicN lrw for thc followhg twtr (Sc.7031.5 <br />Buiocs ard hofsion Codc): Atry City or Cou[ty which rcquirc a pcmh to @Btruct, ghq, improvg darolish or Epair uy <br />struclEc. prior to it! ilswcc slso rcquiG thc eplicat for luch pcmt to filc a signcd stalmt thal hr or Sc b licdscd ptrudt <br />ro thc provisioG of thc Contr8ctor's Licasod Lrw (Ctapt6 9. Commcing with Sctiotr 7000 of Divisiou 3 of thc BciB ed <br />Profeiom Codc) or thst hc or shc is qmpt thsctom md thc b6is for thc alhgcd ampion. Any violation of Sc.tbn 7031.5 by oy <br />applimt for a panrit subjets thc applicilt to I civil pcElty of not morc the fivc hundlcd do[aB (9500). <br />-1, <br />as owner of the property. or my employees with wages as their sole compensation. will do the work and the stnrture b not <br />intcnded oroffered for salc (Sec.7044, Business and hofesions Code: The Contractor's Licerse Law does not apply to an owner of <br />the property who builds or improvc tlreroru and who does zuch work himself or hcrsclf or through his or hcr own employee. <br />providcd that such improvanants arc not intended oroffcred for sale. I[, howwo. thc building or improvement is sold within onc ]Gar <br />of complaion, the Orvner Buildcr will have the hrden of proving tha he or she did not build or imprrove the propaty for the purposcof <br />sale). <br />-1, <br />as owner of the property, am exclusively contracting with licensed contractos to construct the project (Sec. 7044, Busincss <br />and Ptofission Codc: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, <br />and who contracls for such projects with a Conhactor(s) licarsed pursuant to thc Contractor's Liccnsc law). <br />_l am excmpt under B. & P.C. for this reason. <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hereby allirm under penalty of pcrjury one of the following dcclarations: <br />_l have and will maintain a Certifrcate of Consent to Self-lnsure for workers'compensation. as p,rovided for by Section 3700 of the <br />Labor Code, for thc pcrformance of the work for which thc pcrrnit is issued. <br />_l have and will maintain workers' comp€nsation insurance, as required by Scction 3700 of the Labor Code, for the performance of <br />the work <br />G <br />for which this permit is issued compensation carrier and policy number are:, <br />Policy z <br />_l ccrtify that in the performance of the work for which this perrnit is issued. I shall not employ any person in any manner <br />so as to bccome subject to the workers' compensation laws of California. and agrcc that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall, forthwilh comply with those provisions.. <br />r, <br />WARNING: Failure to sccure workers' compensation coveragc is unlawful. and shall subject an to criminal and <br />civil fines up to one hundred thousand dollars ($100.000), in addition to the cost of for the <br />Section 3076 of the Labor Code. interest and fe€s. <br />/ 9t <br />LICENSED CON'TRACTOR <br />DECLARA'TION <br />I hereby affirm under penalty of perjury that I am licensed under provision rvith Section 7000) of Division 3 <br />of the Business and Professions Code, md my license is in full force ard effect. <br />2 ) <br />I h@by affm uds pqu.lty of pajury thd th@ is I ondructio! kodir8 agdy for thc prfuffic of thc mtt for which thb panit is <br />isucd (Sc. 3097, Civ. C.). <br />Lender's Name: <br />Lender's Address: <br />A,'LICANT DECLARATT,N <br />I hereby affirm undcr pcnalty of pcrjury one of the following declarations: <br />Demolition Pcrmits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />-Required <br />Letter o f Notification <br />_l certiff that the federal regulations regarding asbestos removal are not applicable to this project. <br />t-l catify that I have read this I agree to comply with all City and County <br />ordinances and State Laws of this City and County to enter upon the <br />above rnentioned property for <br />Applicant or Agent <br />Perrnitee name <br />state that <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment ra <br />t)At-c l-l(2qvpru to-134t u1,/.77\ <br />Duct Work \-/ <br />Pre-lnsulation <br />!nsulation <br />Smoke Detectors Installed <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Drver <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type ll 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 -t t-l , <br />FINAL t9 rt A >KV>i <br />Notes, Remarks, Etc.--- <br />lc>t3-2il Zul \LD 16 cAtL BK*- ftvFttlAz <br />AF:T\LYO4t '- lHSn&grJ <br />, <br />License ct.*, B' <br />""+fl <br />nL <br />;,il <br />F,0f+*3ui{i <br />LJL]