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M ECHAN ICAL.I NSPECTOR RECORD <br />APPROVALS DATE !D/SIG.COMMENTS OWNER BUTTDER DEI..CARATION <br />I hccby affm uDdE poslty of pcjury thd I m qmpl from thc CodaloE' Lic@ lx for tltc folbwing rcn (Se.70315 <br />Buincs ad Prcfsion Codr): Auy City or County which rcquin a pamt to mnsruct, altq. inprcvc. danolish or rcpair my <br />struchrc. Fbr to its isrc, also rcquirc th3 appliffit for $ch pcnit to 6lc a signcd stslmt thrt hc or slE b licqscd prsun <br />to thc provisiom of thc Cotrtr&c{or's Licoscd Law (Chapt6 9, Commcing with Sctior 7000 of Divisior 3 of thc BuiK 6d <br />Prcf*iorCodc)orthrthcorshcbqmptthqc&om&dahcbrsbforUcsllcgodadption. AnyviolatioaofselionT03l.5byuy <br />applirot for a p6mit subjcts thc 4plicmt to a civil pmlty of not mrc thao fwc hundrcd dollan ($500). <br />-1, <br />a omq of thc Eopqty, or my mployE with wagB s thcir olc ompqsaion, will do thc wq* ad tlE !tuutre b mt <br />intqrdcd or ofrcrd for slc (Sc.7044, BBiB md Proftsgiom Codc: Thc Crotnclor's Licw t w do6 lot qply to & ow of <br />ihc prcpqfy who buil& or inpros tlspn ard who doe ruh wrt hidf or h@lf or thmugh his or ha om qlplols, <br />prcvidcd that such improvumts rc mt imodcd or oftrcd for sale If, howrc, thc hrildi4 or inpoowut is sld wilhitr ooc )s <br />of ompknion, thc O{va6 BuiUc will haw th hrda of proving tha hc or drc dll mt hrild tr inprcrc 0rc pmpcty br thc prpcs of <br />elc). <br />-1. <br />I om6 of thc Fopqty, m qclwiwly cortractitrg with licdscd ontracloB to oEtruct th€ projct (S*. 7044, Buiae <br />ard hoftssim Co&: Thc Costractor's LicG@ Law do6 rct rpply to u oM6 of prcpdy who builds or improB th@r" <br />md who otrtsacts for such Fojccis with I Coofscto(s) licq8cd puEuaot lo thc Cortaclor's Lirc Ls). <br />-l <br />m cxmpt urd6 S€{iotr-, B. & P.C. for this t@n. <br />O*ner' <br />WORKERS' COMP"NSAIU <br />DECLARATION <br />one of the following declarations:I hereby alTinn under penalty of pojury <br />_l have and will maintain a Cerrificate of Consert to Self-lnsure for workers' compensation. as provided for by Section 3700 of the <br />l-abor Code for the pcrformancc of the work for which the permit is issucd. <br />_l have and will maintain Section 3700 of the Labor Code, for the pcrformance of <br />the work for which this carrier and policy numbr are: <br />Irolz tPolicylo| ( | -l_l certi& that in the performance of the work for which this pcrmit is issued. I shall not employ any person in any manner <br />so as to become subject to the workcrs'comp€nsation laws of Cdifornia, and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the labor Code. I shall. forthwith comply with thosc provisions.. <br />WARNING: Failure to secure workers' compensation coverage is unlawful,subjerct an ernployer to criminal perulties and <br />civil fines up lo one hundrcd thousand dollars ($100.000), in addition to the damages as provided for thc <br />Section 3076 of the labor Code, interest and attorney's fees.\t <br />DTCII\RATION .. <br />I hcreby aflirm under penalty of perjury that I am liccrucd undcr provision of Chapto 9 (commencing with Section 7000) ol Division 3 <br />of the Business urd Professions Code, md my licensc is in full forcc ad effect. <br />q 5License <br />CONSTRUCTTON LENDING AGENCY <br />there is a construcrtion lcnding agency for the performance of the work for which this perrnit isI hcreby affrm under pcnalty of perjury tha <br />issued (Sec. 3097, Civ. C.). <br />lrnder's Name: <br />APP' ICA^IT DECLAMT <br />I hcr*D/ afnrm under penalty of perjury one of the following declarations: <br />Dcmolition Pennits-Asbestos Notification Federal Regulations (Title 40, Pan6) <br />_Required Later of Notification <br />with all City and County <br />and County to ent€r upon the <br />-,Ll-yhl <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <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 <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.0- la-2 |**f tl> <br />Final Test <br />Meter Release <br />FINAL ?-t?-? t D,^<, IZ <br />Notes, Remarks, Etc.Art, fufge*. r(S*.or-,