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M ECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS ()lvNt:R nult,r)uR IrEl-cARA'n()N <br />rPI)lictiltli,rtl)rJtrlil\uhiccl\lhc ilpl)licrrlkrrcivilpcnrlly(,lnr)lnx)rclhxnli\chun(lrcd(lolllrs(35(X)). <br />\:rlc ). <br />tn(l $h0 c()ntrilcls liI such pr).icels siltl r (l)rilrilcl()(\) liccilsc(l pur\lrrnl (, lhe (inilrir(lor'\ l.iccnsc l-rN ). <br />-l <br />am cxcmpt under B, <br />[)olci ?120 ()rrnar: <br />I hcrchy atfirm undcr pcnally oI pcrjury onc of thc following dccldralions: <br />_l huvc and will nuintain a Ccnificatc of Conscnt to SelFlnsurc lirr workers cornpcnsillt)n. as providcd frrr by Scction 3700 of thc <br />Lrthr C(xlc. for lhc pcrformancc of lhc work for which thc pcrmil is issuccl. <br />_l havc und will nuintain workcrs conrlrcnsution insurrncc. as requircd hy Scclion 37U) oflhc l,abor Codc. for lhc lErfonnance of <br />the work for which lhis pctrnit is issud. My workcrs' comJrcnsali(ilI irrsurilncc caricr and policy numbcr arc: <br />?-*i^.. <br />PolicY Numhcr: Exnir"t' <br />- <br />_l ccrlily lhflt in thc pcrfornuncc of thc work for which lhir pcrmit is issucd. I shall not cmpk)y any pcrson in any manner <br />$ as k) hccotrrc suhFct to thc workcrs' compcnsat ion lnws of Cdlifornia. and agrN I hnl if I should hccorc subFct to thc <br />workcrs'contpcnsdtionpmvisionsoISslion.3?U]ofthctJh)r(ixlc.lshall.forthwilhcomplywilhlhorcprovisions.. <br />I{ARNING: Failurc to wurc workcm'compcnsalkrn covcragc is urlawful. and shall suhject an cmplolcr lo oiminsl FElties and <br />civil fines up to orc hundrcd thoussnd dolltrs ($100.000). in <br />sEtion 3076 of thc t*nr Codc. intercst ed attomy's fccs. <br />lo thc cosl of comlEnsalion. damges &s providcd fo] tlrc <br />u,u",Q-7Q-ZOU <br />IICENII|LCQNIIA.CIQB <br />DECI ARA'TION <br />I hcBby allirm undcr pcnalty of p.rjury thlt I an liccnsctl under provision ol Chaf,tcr 9 (connrEncing wilh Sccthn 7ff)0) of l)ivision 3 <br />o[ thc Busirrcss and l'rolcssirns Codc. ad nty liccnsc is i[ Iull lorcc and cflccl. <br />Liccnsc Class:-Liccnsc Numhcr: <br />l)nlr <br />W <br />I hcrcby xflirm ufdcr Ircnulty of tErjury that thcrc is il conslruclion hnding agcncy fo, lhc lrcrfornuncc oflhc work for which lhis fErmil is <br />irsucd (Scc..l(,97. Civ. C.). <br />hndcr's Nanrc: <br />lrndcr's Addrcss: <br />APPLICAN'I' I)DCI,ARAl'ION <br />I lf,ltbr allirrn urdcr l)cnxhy ol'pcr iury (rrc (rf thc lirlkru ing rlcclarat ions <br />l)cnx)lilion I'ernrit(-A\lr\lo\ N({ili(rlion I:c(lcrnl Rcgulnliors ( l illc.lO. l'ilr16) <br />_Rcquilc(l l-ctlcr ('l Nrilili( rliur <br />-l <br />ccrlily lhrl lhc lltlcrrl rcgulalions rcgar(linE r\h+slos rcrilr,1illilrc n({ nl)f licilhlc lo lhi\ projccl. <br />-l <br />crrlil.v lhrl I hnve rci(l lhis rppli(nlion nn(l slrlc lhrl lhc irh)!. inl()fltlrlion is c(irrccl. I ilgrcc lo crrnrply <br />: rcl)rc\cnlnlivcs 0l this City <br />with all Cily rnd County <br />and Counly to cntcr upon thcordinnnccs and Stalc lrws rclating to building ud hcrchy aulhorizc <br />rho\c nlcrlirnN(l l)r()pcrly litr i <br />nppliexill (tr ABcnl Signrlurc: <br />Pcrnlilcc narrc (prirl):Cossa <br />,r,,r.,?-13-:?!4 <br />Appliances <br />liletal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />lvlisc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openinos <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech <br />FinalTest <br />Meter Release <br />FINAL lo 4-@ l-Ltr,)21t4c. n <br />Notes, Remarks, Etc