|
APPROVALS DATE ID/SIG.
<br />Appliances
<br />Metal Fire Place
<br />Evap Cooler
<br />Furnace
<br />Compressor
<br />M isc. Equipment
<br />Duct Work
<br />Pre-Insulation
<br />Insulation
<br />Smoke Detectors Installed
<br />Rough Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Range
<br />Other
<br />Hood
<br />T ype I Hood
<br />Type II Hood
<br />Grease Du ct
<br />Fire Damper
<br />Openings
<br />Installation
<br />F .D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />1
<br />Rough Mech . k/0111
<br />Final Test I I I
<br />Meter Release
<br />' I
<br />FINAL
<br />' . I
<br />M :\WP51\Perm,t-lnspeclion Forms\Mecharncal-lnspector Record.doc 03.31.06
<br />MECHANICAL-INSPECTOR RECORD
<br />COMMENTS Owner~Builder Declara tion •
<br />l hcrd>y affirm under penalty o r perjury that I am exempt form the Contraaors ' License: Law for the following rason (s" 703 1.S ~usml!.s
<br />•nd Profession Code). Any City or County which rcquin::s a ~nnit tu construct, alter, improvc, demulish or repair any structure, prior tu its
<br />issuance, also rcquin:s thi: ilpplicant for such permit to file a signed s1a1cmcnt that hi;: or she is licensed pursuant to the provisioll"•O f the
<br />Con~r11.c1or's Licensed Law (Chapter 9, Cumm..:nc ing with Section 7000 of Division 3 of the Business and Professions Cude) o r 1hat h~ 01
<br />she lS exempt therefrom and the basis for the alleged exemption .Any violation ofSeaion 703 1 S by any applica nt for a permit liiubjccts th.:
<br />applicant to a civil penally of not more than five hundrc::d dollars (SSOO). -
<br />_I, as ownc:r ofthc: propc:ny, or my employc:~ with wages as t~ir ~k compc:nsatK>n, will do the work nJ th.! struaure is not 1111entled
<br />o r oflCrc:d for sale ( Scc.7044, Busi~s and ProfessK>ns Code: Thi: Contractor's License Law does not apply to an owner of the: propeny
<br />who builds or improv¢5 thereon, and who do.es such work himself or herself or through his or her own employees, proviJcJ that such
<br />impro\lcmtnls are not intended or ofti:red tb r sale. lf, however, th e building or im provement is sold within one year of compl.:tion, the
<br />Owner-Bui Idec will have: the burden of proving that he or she not build or improve for the purpo!tc: o f sale:).
<br />_ _l, as owner of the propeny, am exclusively contracting with licerued contr1tclors to construct the project ( Sec. 7044, liusine.ss 1111J
<br />Profession Code: The Comr.ictor 's License Law does not apply to an owner of property who builds o r improves 1hercon, and who
<br />conU'3C:lS for such projects with a Contractor(s) lic:en5cd pursuant to the Contraaor's Licens e Law.)
<br />u.,: ,Ull ~;·17/'i:_"o~ 1 h Owno, B. & P.C for lre~--:7--;2-=7, ~.
<br />woiu,:A ~1PF.NSATION ni:ct.At\ATtON .,--
<br />1 herc!by affirm under penalty of perjury one of the following declarations:
<br />I have anJ will maintain a Ccnificate QfConsent to S1:lf-l1uurc for workers' compensation, as provided for by Section 3700 uflhe
<br />Labor Code:, for the: pc1formancc oftlu: work for which lhc pcrmil ii i:isueJ.
<br />I have and will maintain wurktu' comptnsatio n insurance, as required lJy Section 370U of the Labor Cud~, for the pc:rfonrn.111..:e ufthe
<br />;;,,k for which this p.:rmit is issu1.:d My workers' compensation insuranO! carrier anJ rulicy number are:
<br />Cu1il!r : ______________ _
<br />Policy Number: ___ . --,--,-.,.,-,~------________ Expires _
<br />(This .;cction need not be completed if the permit is for One hundrc.d dollars {SlOO) or lco}
<br />--------·-
<br />I certify that in the pc:rformanc:c of the work for which this permit is issut:d, I shall not employ any pc.rson III any manner si:i as tu
<br />~me subject to the wo1kcrs • compensation laws o f California, and agree thal if should become subjecl tu the workc:rs '
<br />compcnsa1 t tOn provisions ofScc;tion 3700 of the Labor Code, I shall, forth~jl compl with thos~ provisions,•
<br />D•lc: / CJ (12 2 I,,) /~ Applica•ll:~~ _, -:7,--""y-, -·-··---~ •~ ~ -,I
<br />WARN ING : Failure to sccurl! workers' compensation coverase i unlawful, and shall subji::c t an em~ycr to cri mimtl p~na ltics and i.:ivil
<br />fines up to one hundred thousand dollars (SI 00,000),in addition to the cost of compensation, dam~ges as pruvide:d for 1hc .Secuon 3076 o f
<br />the Labor Code. interest and auornc:y's fe~.
<br />L.I C:KNSt;p CONTRACl'ORS IH:Cl,A llt\TION
<br />I hereby 11.ffirm undc:1 penalty of pcrJury thilt I am licensed under provision of Chapter 9 (commencmg with Section 7000) of Oiv1s1on 3 i:if
<br />the Businus and Professions Code, anJ my license is in full force and c.ffoc.1
<br />License Class: __ ,.~----_______ License Numb~r _____________ _
<br />Oa1e: _____________ Conuactor: _____________ _
<br />,ONSTKll(7'ION U:NUING A(;f;NC:\'
<br />I hereby affirm under penalty of perjury that thcte is a construc:uon lending agency for the performance o fllk: wurL for winch 1111$ permit ~
<br />issuod (Soc. 3097, Civ. C.).
<br />Lende1's Niuue: __________________________ _
<br />Lend~'s Address. ________________________ _
<br />A l'l'LIC:ANT'S Dt:Cl.i\RATION
<br />Demolit ion Permits-Asbestos Notification Federal Regulations (Tnle 40, Part 6)
<br />_ Rtquired Letter of Notificauon
<br />_I ct:rtify thal the federa l rl!gulations rc:gardin~ t1libcli1os removal arc: not applicable: to lh is p1ojec1
<br />-·_I ccmfy thal I have read this apphcauon and stale that the: above infounauon 1s correcL I agree to co1Hply with all C11y and Cuu111y
<br />orrimances and State Laws relating to bu1~din • nstr ·uun, and he,eby authorl.ZI! rcprl!sentat1vcs uftlus C i1y and Coumy tu cnh:r upon the
<br />above mentK>oc::d propc:rty for in~uon pyrpl) • •
<br />Apphc.•n1or•••n• .. •·---//\ 1 / ,U----J~ ______ Uo10 1.c,_/4'2-2.o.1£.
<br />l'c.-miu•e name(p11111). --12.t-(;;1L L.M~/~~ _____ ---·-__ _
<br />~
|