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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION <br />I ho$y atfm uorla pcndty of pcjury thd I m cxcopt fiom thc Conbscls' LieM Ls for thc hlhwing reo (Sc.?0t1.5' <br />Buine and Profta3iotr Cod!): Any City or Crurly which rcquiro 8 Fmit to oBtruct. rh6. inprcve &aolbh or nprir my <br />structucpriortofu isMccd$rcquiBthcrpplimtforshpqmittofilcssigocdstdqErt thahcorshcblicascd ptmar <br />to thc FovisioE of thc Contrelor'! Lienrcd trw (Chapc 9, Comdcing wih Sctbn 7000 of Division 3 of thc BuiN md <br />Pmfcssiom Codc) or thsr hc or she b dapt tbsc&om md thc bsb for thc allcgcd acaptiotr. Atry violttbo of Sdbtr 7031.5 by uy <br />8pplicut for I p6mit $bjcls thc rpplicut to e civil paalty of mt mrc thu fivc hu&cd dollm ($500). <br />-1, <br />u ow of thc prcFty, or my mplo]6 with waga u thcir slc orrycruaioq will do thc md( ed tlrc stsrrrw b mt <br />intqdod or oftrod for slc (Sc.7044, BBiK md Proftsriou Codc: Thc Contncior's Licre Lrw doc mt spply to m ow of <br />thc Fopqty who bui!& or iqros tbmo. nd who doc mh w* hiroctf or hmlf or thrcugh Ns or hc om oployccs. <br />prcvidcdttatsch improvqmErcDtitrtodGdoroftodbrslelf,how,thcbuiHingcirqoErcdismldwithinorc]qr <br />of oopl*io& thc Owm BuilCr will haw the hsda of povirg thr hc or strc dit mt build tr in4rcrc &c pmFty 6r thc purpoe of <br />sh). <br />-1. <br />s om6 of thc Fopqty, m sclBivcly $rlra.ring with licqBcd cotrtsactoE to sDstrud thr Projct (Sc. 7044, Baird <br />ud Profrsin Co&: Thc Cootnclor's Licce Law do6 mt rpply to m omq of prcpcrty who builds or imprcv6 tb6on. <br />ud who oln8t! for sEh projct3 with I Crohcro(s) lic@lcd pmurd to thc Contndor'! Lic@ kw). <br />-l <br />m qcmpt urda Sclio!--, B. & P.C. for thb @L <br />0wner: <br />DECI,I\RA'TION <br />I hereby affrrm under penalty of perjury one of the follorving declarations: <br />-l <br />have and will maintain a Certificate of Consent to Self-lnsure for \r'orkers' contpensation, as pro!'ided for by Section 3700 of the <br />Labor Code. for the perfonnance of the work for which the pennit is issued. <br />_l have and rvill maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the performance of <br />the work for which this permit is issued. My workers' compensation insurance c.urier and Snlicy number are: <br />lblicy <br />_l cerriff that in the performance of the work for which this permit is issued. I shall not ernploy any person in any manner <br />so &s to become subject to the workers' compensalion laws of California and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code I slull. forthwith comply with those provisions.. <br />WARNTNG: Failure to sccure workers' compensation coverage is unlawful. and shall subject an anployer to criminal porahies and <br />civil frnes up to one hundred thousand dollars ($100.000), in addition to the cost of compensation, damages as Provided for the <br />Section 3076 of the l-abor Code interest and attorney's fees. <br />Dete: <br />I ICFNSEIT CONTRACTOR <br />DF'CI.ARATION <br />I hereby affrm under penalty of perjury that I am licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 <br />of the Business and Profcssions Code. and my license is in full force and effect. <br />Licensecturr, 0 LicenseNurnber: <br />gZStt ftl <br />flolo' <br />C(}NS'I'RTI("TI()N I,I,N DI NC AG I.'N('\' <br />I hrcby affm unda Fnrlry of pcdury thal th@ b a snsruction kndioS ag6cy for rhc pcfomcc of thc uork for which this pqmit k <br />issued (Sec. 3097, Civ. C.). <br />Lender's Ad&ess: <br />APPI ICAN'T DECLAITATION <br />I hercby affirm under penalty of perjury one of the following declarations: <br />Dernolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Pan6) <br />-Required <br />Letter of Notilication <br />-l <br />cdiry that thc fcdq8l rcgularioG regading rbstos ronoval re not 4plicablc to this prcjcl. <br />-l <br />cdiry that I havc read this application ed statc that thc abovc infomalion is conct. I agc lo comply with 8ll Cilyatrd Counly <br />ordinecG ed Stat€ t ws rclsting to buildiog constructio& dd hseby authorizc rc?rGatativo of this City md County to mts upon thc <br />above mmtioned prcpcaly for i$p€lion purpos. <br />Applicant or Agert <br />Pennitee name (orint): <br />I ),rt t'. <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 Dryer <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type Il 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. <br />Final Test <br />Meter Release I I I L /-ry <br />FINAL i I I <br />J (/),DKV>/ <br />Notes, Remarks, Etc.I I <br />Drte:_ <br />Annlicant: \/ <br />contrecto.' \(.