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M ECHAN ICAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/S!G.COMMENTS OWNERBUILDERDEICARATION t <br />I lHcb, affim undE pcnaly of pejury tha I m qmpt ftom thc ContnctoB' Licmrc Llw for thc following ren (Sc.703t.5o <br />Bwins sd Proftssion Codc): Aoy City or County which rcquiro a pcmit to oBtruct, alta. imprcvc damli:h or npah uy <br />sttucruc. priu to it3 ilswc, slso rcquiB thc eplicilt for s$h pcrmit to filc a signcd $dsmt th8t hc or lhc b licmcd puoa <br />to thc provisioE of thc Contrelor'! Lienrcd L:w (Chapts 9, Commcrcitrg with Scrion 7000 of Division 3 of thc BGincas ed <br />PrcfNioE Codc) or that hc or shc b qopt thcc&oo and thc bcis for thc alcgcd mption. Any viohtion of Sctiotr 7031.5 by uy <br />applimtforEpqmitlubjetsthc gpplicettoacivilpcoiltyofmtmorcthfifivchundrcddollan($500). <br />-1, <br />a ffi of thc poparn c my mglo1a with wag6 I thcir $lc onpasaion will do thc uoil ud th€ srudrc b mt <br />intqdcd or offmd for ulc (Sc.7044, Buim md Proft$ioro Codc Thc Contnctor's LiccM lrw do6 trol spply to u omc of <br />thc prcpqty who huil& or imprcs tlE@n, md who doc uh rcrt hiructf or h*lf or thrcugh hb or h6 om mployo. <br />provkiod thar such impovmts rc mt iaodcd oroftrcd 6r sh. I[ how. th buiEing or in4rcwncm is rcH within w ]q <br />ofonpl:tbn, thc Orvtrs Buitds will harc thc burda ofpoviry tha hc or shc did mt buiE m improrc thc prcpaty br thc purporc of <br />elc). <br />-1. <br />u oma of thc ![opGty. m ffluivcly contracling with licans€d coilractoB to oEtuci thG ptojet (56. 7044. &Bins <br />ard Proftsin Codc: Thc contnclor's Liccre Law doq mt apply to e omq of propsry who buil& or imprcvB tbqotr' <br />ud who srhactr frr swh prcjets whh 8 Cortsacto(3) licascd prlEutrt lo thc Contnclor'! Liw Lsw). <br />_l m cxmpt urda S61ioD-. B. & P.C. forthis lu$n. <br />}YORKERS' CONT PENSA'I'ION <br />DECLARATION <br />I hereby affirm under pcnalty of perjury one of the follorving dcclarations: <br />_l have and will maintain a Certificate of Consent to Self-lnsure for workers' c()nlpensalion, as provided for by Section -3700 of the <br />labor Code. for the poformance of the \,\'ork for u'hich the pennit is issued. <br />{t hou" and will maintain workers' cotnpensation insurance. as required by Section -1700 of the Labor Code. for the performance of <br />the u'ork for rvhich thls permit is issued. My workers' cornpensation insurance carrier and gnlicy number are: <br />o <br />Policy \tl o lol lu)o <br />WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subject an anployer to oiminal paulties and <br />civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. damages as provided for the <br />Section 3076 of the tabor Code, interest and attorney's fees. <br />o)O <br />LTCENSED CONTRACTOR <br />Dr.cl ArtATroN <br />I hereby affrm under paralty of perjury that I am licensod under prrovision of Chapter 9 (commencing with Section 7000) of Division 3 <br />of thc Business and Professioru Code. and my license is in full force and effect. <br />Licensecr.rr, ()Or(td <br />LicenseNumber:4qS)Lo <br />D",., l.l / 6 /I 6)0 <br />W <br />I ho*y affirm udo p@slty of pajury thd thc b . @nstruclbo koding ag6cy for thc pqfomcc of thc wrk hr which this pmit b <br />isucd (Se. 3097, Civ. C.). <br />Lender's Name <br />Lender's Address: <br />^ rr, ,cAN, ""c, RAT <br />I herelry afnrm under poralty of perjury one of the following declarations: <br />Demolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />-Required <br />Letter of Notification <br />-l <br />csriry thst thc lidcral rcgulatioro rcgarding rbatos moval ac not 4plicable to this prcjc{. <br />-l <br />cdiry thd I havc Md this application ed statc thd thc abovc informaion is concl. I agc to smply with all City aDd County <br />ordimcB ed Statc Lrw rcl8lirg to building cor$ructiorr ed h@by authorirc rcprstativB of thb City md County to at6 upon th€ <br />above mentioned property for inspecfion <br />PLApplicant or Agent <br />rtsPennitee <br />purposcs. <br />** t\ /(/)olo <br />Appliances <br />Metal 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 />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type II 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 -/ <br />FINAL l4'?."1h D\PKD"r <br />Notes, Remarks, Etc. <br />Date:Owner: <br />_l certifu that in the performance of the work for which this pcrmit is issued. I shall not ernploy any person in any manner <br />so asi to become subject to the workers' compensation 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 sha[. forthwith cornply with thosc provisions.. <br />-