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MECHANICAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/S!G.COMMENTS OWNER BUILI'ER I'EI.CARATTON <br />t hacby aIfim uda poulty of pqjury ttd I m q@F EoD th Cotrrel6' Licre l:w for thc folbwjog ta$n (SGc.703!.5 <br />Buias od Profebn Codc): Any Ciy or Couny which r€qui!6 8 pqnii to srrtnrct, altc, improvc, &mlish or Epon my. <br />itrudqr. Fir to its isrc, also rcquiB thc applicet for sh p6mit to 6lc a sigtr d stdmt thd hc or shc b licqscd pwat <br />to thc FovisioB of thE Contractor's Licascd Lrw (Chapta 9, Comming with Sctiotr 7000 of Divisio! 3 of thc Buim md <br />hofcssiou Codc) or that hc or drc is qqnpt thftfrom ud thc bcis for thc allcacd cxmpion Any violation of Sctbn ?031.5 by uy <br />spplicmt for a p6mit subjcts thc applicant to s clvil paalty ofnot morc thm livc hun&d doltas ($500). <br />!&, * ow of thc propsty. or my cmplole with wsg6 a thck $lc 6mpasdio!. wil do thc mrk od UE stnnw b mt <br />Eqlcd or ofraod for slc (Sc.7044, BBiB md Pl.ofeiou Codc: Thc Co!trG{or'3 Liw lrw do6 not eply to m ow of <br />tlr Fopqty who hrilds or implou theon, ud who dos sh mit hielf or ha$lf or thrcugh his q hs om aplo,rccs, <br />prcvircd th8t reh improiqms rc ml iotodod oroftrcd for slc, l[ how, the huiHing q itqrowm b $ld within orc ]ar <br />of onplabr, the OwE Builda will harc thc hrda of prcviog thr lrc or shc dil Dl tuild q inprcw tbc popaty br tlr prpo* of <br />$h). <br />-1, <br />u ow ofthc prcporn m acluively offeting with licqEcd coniactoF to @Etrucl th. Fojd (S6. 7044, Buin6 <br />and Pnftssin Co&: Thc Contraclor's Licmc I:w doc not apply to m oma of prcpoty who buil& or iEproB thq@n, <br />ed who ontracls for such projd! with a Contraclo(s) Iicstscd pmuad to thc Contrrclor's Licre kw). <br />-l <br />m *mpt udq Scthn-, B. & P.C. for this ren. <br />( <br />I hereby affirm under pcnalty <br />_I have and will maintain a Cciliftcate of Conscnt to Self-lnsure for workers' comparation, as p,rovidcd for by Section 3700 of the <br />Labor Code for the performancc of the work for which the pennit is issued. <br />-l <br />have and will maintain workers' compensation insurance. as requird by Section 3700 of the Iabor Code, for the performance of <br />the work for which this permit is issucd My workers' compcnsation insurance carrier and policy numhr arc: <br />Policv Numbcr: Exoires:, <br />I !\ccrtiry that in the pcrformance of the work for which this pcrmit is issued" I shall not anptoy any person in any manncrf6as to become subject to thc workers'compensation taws of Catiforniq and agree that if I should become subjcct to the <br />workers' compensation provisions of Section 3700 of the tabor Code, I shall, forthwith comply with those provisions.. <br />WARNING: Failure to sccure workers' comperuation coverage is unlawful. and shall subject an employer to oiminal pcnaltics and <br />civil fines up to one hundred thousand dollars ($100.000), in addition to the cos of compcnsstion. damages as provided for the <br />Section 3076 of the Labor Code, interest and attorn€y's fecs.^Z t/t o \(= A?- s/ <br />LICENSED (:ONTRACI'OR <br />DT'fL\RATTON <br />I hereby affrm under penalty of perjury that I am liceosod undcr pmovision of Chapter 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code, and my license is in full force and effect. <br />License Class: License Number: <br />l)irtc <br />W <br />I hq*yaIImundqpauhyof pojurythat tlEcbI@o{ruclbn hoditrg8gtry forthcpcfotwofthcwr|( bru/hich$bpqnil b <br />issucd (Sc. 3097, Civ. C.). <br />Lender's Name: <br />tads'sAdd6: <br />m <br />I hftby alforn und6 poalty of pcrjury onc of thc following dclrations: <br />Dcmolilion Pmils-Asb6tos Notification FcdEal Rcgulations (Titlc 40, Pan6) <br />-Rcquired <br />trtt6 of Notification <br />-l <br />cqliry thd thc fcdaal rcgulatiom rcgading cbetos rmoval uc not applicsble to this pmjet. <br />.I) <br />*-fcertifu tha I hEvc ud this application {d state thd thc abovc infomation is corr€l. I agr to comply with all City md County <br />ordimncG ed statc llws rchting to building consrruaion. ard hacby authorize rcprffitativ6 of this Cily ed Couty to f,tq upon 0rc <br />abovc motioncd prcpsty for iNpetion purpo$ <br />Ke, ?4^ <br />I sl \t-o k-. <br />/e--,.(.? -a <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace tl,?(-Ll L '/;S-tl ,f) <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors Installed <br />Rouqh Ductwork <br />Vents <br />Toilet Room / Clothes Dryer ,/, 1l- V{ i I dt|rt 7 <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type II 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 n <br />Meter Release ,'1r\ <br />FINAL -)-\G-A \r\[-\rl <br />z <br />Applicant: I <br />Contractor: <br />Applicant or Agent Signature: .4 € <br />Pcrnritccname @lrt}, I eY< <br />/ <br />Notes, Remarks, Etc.v \,