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M ECHANICAL.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUIII'ER IIEIIARATION \ <br />I h@by 8l6rm udc pauty of pcjury tha I u a@pt from th€ Crrilractm' Lic@ Is for thc folowitrg Iren (Soc.703l-.5 <br />Bsin6s ard Prof6sion Codc): Any City or Couty which rcquirB I pqmit to @rstdcl, altq, imprcvq danolish or npeir uy <br />structurc.Fiortoit! isusrcc.alsorcquirBthcrpplimtforsuchpamittofilc8siSncdstatmt thdhcorshcblisscd putlwt <br />to thc fovi3ioB of th. Cootetor's Licmscd kw (Ctaptq 9, Comacing with Se{ioo 7000 of Division 3 of thc BsiK md <br />Profcsioro Codc) or that hc or shc is qmpt thqcfrom ud thc basis for thc dl€gcd qmpion. Any violation of Setbo 703 I .5 by uy <br />applicut for I pnnit subjcls thc applicet to a civil pculty of rct morc the fivc hundrcd dollar ($500). <br />-1, <br />I oM6 of thc propqty. or Ey mplo)6 with wagc u thcir mlc ompqsation, will do thc wqk ad thc srudw i! mt <br />irtqrdcd or ofiard for slc (Sc.7044, BBiK ed ProfcsioB Codc: Thc Contractor's Licqe Lrw do6 trot apply to e ow of <br />thc popqty who boil& or irqros tlren ad who ds uh rcr* hirelf or hmlf or thrcugh his or hc om mployccs, <br />prcvidcd thar such imprcwrs e mt intodcd or oftrcd 6r sb. t[ how, thc hduiag u fuprcErcnr ir $ld within onc ]@ <br />of omplctiorl thc Oma BuilCs wil h8w tlrc hrd6 of prcving tha hc or slrc dil mt buiH or improrc thc popaty 6r thc prpo* of <br />sb). <br />-1. <br />r omq of thc pmpsty, e aclEivcly cortracting with lic@sod coilfftoB to mn$ruct tlE prcjcct (Sc. 7044, BuilB <br />md Pmfosbn Codc: Thc Contrctor's Lic@c Law doB not apply to e omq of prcpqty who buil& or iEprcvB thqotr, <br />md who omnas for such prcirs whh 8 Corilruro(s) licalcd pwuad lo thc Cotrbstor's Licre ls). <br />-l <br />m cxmDt utrds Sction- B. & P.C. for this tEen. <br />WORKERS'COMPENSATION <br />DES.AEAIION <br />I hcby aflim uda poralty of pcjury onc of thc following ddlaratioE: <br />-lhavcudwillmintsinaCedificateofCoNmttoSclf-lNurcforwrk6'compcsation,s <br />providedforbySetion3T00ofthc <br />tibor Codc, for thc pgfomcc of the work for which thc pqrnit b issucd. <br />&{ havc and witt maintain workc' ompmation iruurucc, 6 requircd by Setion 3700 of thc lrbor codc, for thc pqforlwcc of' ihC rcrk for which this pomit is issucd My workc' compeusaion insuucc cilis srd policy nmb6 &c:o\ <br />oLl Irttt]x <br />_l certify that in thc performanc€ of the work for which this permit is issued, I shall not employ any person in any manner <br />so as to become subject to the workers' compcnsation laws of California. and agree that if I should become subject to the <br />workers' compensation provisions of Sedion 3700 of the labor Code I shall, forthwilh comply with those provisions.. <br />WARNING: Failure to secure workers' compcosation coverage is unlawful, and shall subject an onployer to oiminal pcnahies and <br />civil fines up to one hundred thousand dollars ($l in addition to the cost of compensation. damages as provided for the <br />Section 3076 of the Labor Code, interest and attorney's t ( <br />LICENSED CONTRACTOR <br />DECI.,ARATTON <br />I hoeby aflirm under pcnalty of pcrjury that I am licensed under provision of Chapter 9 (cornmencing with Section 7000) of Division 3 <br />of the Business and Professions Code, and my license is in full force and effect. <br />6b4q.t5License <br />/( <br />W <br />I hatDy aIfim uda pauhy of pajury thd th@ is a oo*ruaion kding agmy for thc pcfomcc of thc worl br which thb pf,iit b <br />isucd (Se. 3097, Civ. C.). <br />Lender's Name: <br />Lender's Address: <br />APPLT.ANT DEC <br />I hed}, affirm under peralty of perjury one of the following declarations: <br />Dcrnolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />-Requircd <br />Lrtter of Notification <br />ffiili*-ffi-#"ffiffiffi-ffiHfi HY;r'.1'":,li*ff H"* <br />above mentioned property for <br />Applicant or Agent <br />Pcnnitee name <br />Appliances <br />Meta! Fire Place <br />Evaporative Cooler tl <br />Furnace +'it,.A <br />Compressor -l 1 l"/ "t*(uy <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors Installed <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type Il 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 />Rouqh Mech. <br />Final Test <br />Meter Release I I .-- <br />FINAL C lzlzt O.O ru9 <br />Notes, Remarks, Etc.,I <br />",,",?El l[bl)l , <br />Date: