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APPROVALS DATE !D/SIG COMMENTS OE-Buildr3 Dclrntio! <br />t bacby rffrn uda paalty of pcjury that I u aop fom thc Coutrrcton' Licw llsw hr tbe followiag reoo{rpc.703l.5,Buire' <br />rad Proft*rioa Codc): A[y Ciry or Courty which rcquic a panir to oatnrct, !hq, iE!rcvc, doolisb or rcpqir ay rtrucrre, pior ro 11 ' <br />isw, abo rcquic thc rppliut for such pmit to filG r !t!cd nst@6t th'r hc or rhc is tic@d puEt to thc pmvisioa of thc ' ' <br />Comrror's Licanod hw (Chapc 9, ComiDg *tuh Setioa 7000 of Divirbl 3 of thc Buins ed Profcaioa Co&) or tba bc c . <br />3hc it ffiF rhac&oE Ed th.b8i! for th. rtlcgod qaptio[ .Ary violaion of Serion 7031.5 ry ey lppliut br rpcr4ir $bj6t thc <br />rp,plicary o a civil poalty of mt mrc ths 6vc hudrcd dolles ($500). <br />/, u ow of thc prcpcty, or my aplolE with w!g6 I tbct $L coEpasdioD, will do tic wort ed tbc ltru.ie ir mr intcodcd <br />or offed for salc ( Sc.7044, BuiB &d ho&*rbu Co&: Thc Cotncru's Lire Law do6 mt lpply to e onas of thc prcpsty <br />wbo buildr or ioprcva ttgEo, ud who doc uh rcrh tirelf o hmlf or tkoqh his or hE om apby6, Foyidcd thar och <br />iEprcv@@$ e mt irtddod or offacd for !.la l{, bowa, tl3 tuildiag or improvoot ir rcld withia orc ya of oEplctioq thc <br />Ow-Buildc will hrvc thc hrda of proviag tbsl hc or rhc lot build or iDprcvc for thc pupor of rdc). <br />_I, a ow of thc propaty, u xlusivcly contrrcring with licasod coilrutoB to oDsrfft thc p(ojet ( Sc. 7044, Buina ud <br />Prcf€sb! Co&: Tbr Cotrraor'r Liru I:w doB Dot rpply to e ow of popaty who builds d iDprov6 th@r , ud who <br />6ntr&t! 6r such psojct! with a Cutrrctd(s) licasod pus@l to lbc Colne{or's Lirc hw.). <br />_I u d6pt ulds Sctioa <br />-8. <br />& P.C. for6ir ffior <br />I hcreby afErm undcr pcoalty ofpcrjury one <br />I bflc ed will Dsi[tri! r Catific{c of CoMt to ScU-lDse for mrkd' coD@stio!, I Fovidcd for by Sctioo 3700 of thc <br />Lrbor Cod., for the psfom of tlc rcrt for which ttc pcnit is isucd <br />I hrvc 6d viU uidri! mrta' orporaioo iasurmc, s rcquirod by Serion 3700 of thc L$or Codc' for thc pcrforruc of thc <br />wo* for which this pcnit is isucd. My rcrta' @Epcu.tio! imcc mic ud policy auba uc: <br />Policy <br />(This scction not bc completod if thc permit is for Ooc hua&ed dollars (5100) or less) <br />y'catify that in thc pcrforoancc of thc wort for which this pcrmit is issuc4 [ shall not cmploy atry pcrsoo in aoy menncrso as to <br />6ecame rubject to thc workers ' compensation laws of Californiq and qgrec that if I should becomc subjcct to the workas' <br />compensation provisions of Scctioo 3700 of thc Labor CodC I shall, fonhwith comply with thosc provisions.. <br />WARNING: Failure to sccurc worketrs' <br />fincs up to one hun&ed thorsand dollan <br />compclulation <br />($100,000),in addition <br />thc LrborCodG, irt6t rodrrmy'r fa. <br />@ <br />I hqdy rtrE uod.r pculy of Fjury tha I m licancd uda p,ovirio! of Ct!p6 9 (@mcocing with Scctioa 7m0) of Divirioa 3 of <br />thcBr!i!4 adProftsriosCodc, udnylicalc i! i! ful foreEd.frct. <br />Licensc Class: Liccnsc Numbcr <br />Datc: Contractor: <br />W <br />I bscby sfnrE uidc( pofty of pcjury that th6c is . coEtructior lading agmy for thc pafot@cc of thc wort for which thir pcmit ir <br />ircurd (S€c. 3097, Civ. C.). <br />l.coder's Address: <br />APPLICANT'S DECLARATION <br />Regulations (Titlc 40, Pan 6)Demolition Pcrmits-Asbcstos Notification Fcdcral <br />_ Rcquired Irtter of Notification <br />-I]rdriry <br />tbrt thc &dsrl rcgulrtiou rcgrding rbstor mval rc mt lpPlicrblc to thi! Fojct' <br />'I*,ifrrhrthrr"radrhitrylicrrbnEdn.tcthlrthr&orcidomdboirorc.t.IrgEtocooplywirhrtlChyedcouttyordi@6 r[d Stnc bu ddilg to hilding c.ufrrfioq ud bcby uthorizo r?r.aatativcs of this City ud Couty to ata upol t[r <br />lbovc Ediorcd propoty br iaspctioa purpora. <br />Applicant or agcnt <br />Permittec name <br />d- <br />Appliances <br />Metal Fire Place <br />Evap Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />Insulation <br />Smoke Detectors Installed <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release I I <br />FINAL (/+l4t VW w <br />I <br />I <br />M ECHANICAL.I NSPECTOR RECORD \ <br />Word\wp51\Forms\Permit. -lnspection Forms 03.31.06