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M ECHANICAL.I NSPECTOR RECORD <br />APPROVALS DATE IDTSIG.GOMMENTS OWNER BUILDER T'ETTARATION <br />I h6cby slfim unda paulty of pcjury thst I @ 6cmtr 6om thc ConbrtoE Licw Lrw for thc following wn (S*.7031.5 <br />Buinss ad Prcfssion Codc): Aay City or Crunty wtich rcquiro a panit to on$rucq alta, improvc, rhmlirh or rcpair my <br />structur. p(br to its isswc., also roquic thc applimt for $ch Fmit to fil€ E sigo€d statmt thd bc or !t3 i3 licascd ptmant <br />to thc provbioro of thc Contractq'r Liccnscd L:w (Chapc 9, Comacitrg with Sctioo 7000 of Divisioo 3 of thc Buirc md <br />PrcfsiomCodc)orthsthctrshcisqmptth6€&omedthcbosisforthcsllcgcdqadion. AnyviolationofsctbnT03l.5ryay <br />appli@t for a p6mit subjets thc applicmt ro a civil porlty of mt morc the fivc hundrcd dollm ($500). <br />-1. <br />c omc of thc pmpqty, or my mph,6 with wag6 a thcir olc omposaion will do thc wort ad rhc strd@ b mt <br />intodcd or offacd for slc (Sc.7044, BuiB ud Pmfeioro Codq Thc Cotrsclocs Licffi Law do6 not apply to m omq of <br />thc propqty who hilds or irqrou thgEn ad who ds sh wrt hirelf or hffitf or thmugh his or h6 om oplolccs. <br />prcvidcd that swh imprcvqmil! rc mt intadcd u olEcd br sb. It howqs. tlrc tuiHirU q irqrovgMi b $ld wthin orc ya <br />of onplaion thc Ovm B[iEa will harc thc hndgr of FoviDg thd hc or slE did mt buiH or imprcvc thc pmpoty Sr thc purpos of <br />sL). <br />-1, <br />6 om6 of thc Fopsty. u scluiwly contreling with licas€d @otratoE to @rdMl th€ pioj61 (Sc. 7044. BciB <br />ad Profusim Codc: Thc CortBctor's Licmc Law dc mt spply lo u omq of prcpqly who builds or imprcv6 thq@D, <br />ud who @ntEcts for such Fojets with 8 Cotrscto(s) licascd p8usrll to thc CoilBclor's Licw L:w). <br />-l <br />m cxcmpt udo setion- B. & P.C. for this lwn. <br />Owner: <br />DECLAITATION <br />I hercby affinn under penalty of perjury one of the following declarations: <br />_l have and rvill maintain a Certihcate of Consent to Self-lnsure for workcrs' cotnpensation. as providd for by Section 3700 of the <br />L^abor Code. for thc performance of the work for which the pcnnit is issued. <br />-l <br />have and 3700 of the Labor Code, for the pcrformance of <br />the work for and policy number are: <br />7SPolicy t <br />-l <br />ceti& that in the performance of the work for which this permit is issued. I shall not employ any in any manner <br />so as to become subject to the workers' compcosation laws of Californra and agree that if I should become subject to the <br />workers' compensation provisions of Scction 3700 of the Labor Code. I shall. forthwilh comply with thosc provisions.. <br />a <br />a <br />WARNING: Failure to sccure workers' compensation covcragc is unlawful. and shall subject an anployer to criminal penalties and <br />civil fines up to onc hundred thousand dollars ($1ryrcOO), in addition to the cost of compcnsation. damages as provided for the-itrSection 3076 interesl- <br />LICENSED CONTRACTOR <br />DECII\RATION <br />I hoeby aflirm undcr penalty of pcrjury that I am lic€oscd under provision of Chaptc 9 (commencing with Section 7000) of Division 3 <br />of the Business and ho ssions Code, md my liceosc is in full force and effoct. <br />c20 A 4oz-qqLLicenseNumbcr: <br />W <br />I h@by sffm mdcr paalty of pcjury th8t th@ b I sns(ruction hding agacy for thc pafomc of thc wort for which this psrnit is <br />isucd (Sc. 3097, Civ. C.). <br />Lcttrlt't 's Nirntr.:: <br />Lender's Address: <br />APPLICAI{T DEC I.ARATION <br />I herl*y affinn under penalty of perjury one of the following declarations: <br />Demolition Permits-Asbestos Notification Fcderal Rcgulations (Title 40, Part6) <br />-Requ <br />ired Lrtter o f Notification <br />-l <br />certi& that the federal regulations regarding asbestos removal are not applicable to this project. <br />\ <br />-l <br />certi& that I hh rcad this applicarion and state that with all City and County <br />and County to erter upon theordinances and State l-aws relating <br />above mentioned property for <br />Applicant or Agent <br />Pennitee name fc <br />2/ <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler I ^-"- <br />Furnace T lLlzt Ft{7) <br />Compressor tl <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />Insulation <br />Smoke Detectors !nstalled <br />Rough 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 />Openinqs <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech <br />Final Test <br />Meter Release /l <br />FINAL '1 lt- ht Ld91 <br />Notes, Remarks, Etc.I <br />Date:_ <br />,