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M ECHANICAL.I NSPECTOR RECORD <br />APPROVALS DATE !D/SIG COMMENTS OWNER BUILIIER DET,CARATION <br />I hcby affm unda p68lty of pqjury that I m qmpt ftom thc Conh&{oB' Liccre L.w for the following l@n (Se.7031.5 <br />Buincs and Profsion Codc): Any City or County which rcquis a psrnit to construct. altE, improvc. danolish or rpair ay <br />structuq prior to iti issureq also rcquic the eplicmt for srch pamit to 6lc a signcd ststarot thd h! or slE b licaEcd puEusf <br />to rhc prcvisioB of thc Contretor's Licoscd L:w (Chspt6 9, Comocing wirh S€liotr 7000 of Divisiotr 3 of thc Buin* ed <br />Profsiom Codc) or that hc or slrc is qcmpt thqctom ud thc basis for thc slcgcd qmplion. Any violation of Setion 7031.5 by ey <br />q)plicmt for a p6mit subjcts thc applicant to 8 civil pcmlty ofnot morc thm llc hundrcd dollaB ($500).c^ <br />-1, <br />I omc of thc popaty, u my mplole with wag6 I thcir sl€ @mpcnsaion vill do thc wo* ad thc *ruqw k mt <br />intadcd oroffrodforslc(Sc.T044.BuinemdProftsiomCodc:ThcContractor'sLirctrudo6mtqplytooomcof <br />thc prcpqty who tuil& or imprc€ thoue ad who do6 wch wrt hiruclf or hmlf or thrcugh his or lE om @phyc. <br />providod ahat such imprcwmts rc rct imodod or olftrod for sh. If, how, thc hrilding or imFovqut b sld within orc )a <br />of onplrbo thc Ovm6 Builda will haE thc hrda of poving tha h or shc dll mt tuild or inForc 0E FoFty fur thc Frpo* of <br />eh). <br />-L <br />a oma of thc popcry, m cxclwivcly cortrethg whh lic€Bcd cotrtractoF to onstrucl thc projcr (Sc. 7il4, Bsine <br />and Eoftsir Codc: Thc Contmtor's Licffi lrw do6 not apply to m omq of propaly who buil& or imprcvB th66D, <br />md who @ntrrcts for such FljEl! with a Cootraclo(s) lic@scd pswt to thc Contrrcror's LicGre t w), <br />I am exemot under B.& <br />?I ) <br />I hereby affrm under penalty of pojury one of the following <br />-l <br />have and will maintain a Ccrtificatc of Consent to Self-lnsure for workers' comperuation, as provided for by Section 3700 of the <br />Labor Code, for thc perfonnancc of the work for which the pennit is issued. <br />_l have and will maintain workers' comperuiation insurance. as required by Section 3700 of the Labor Code, for the pcrformance of <br />the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: <br />a^*i*. <br />Policv <br />c t4', <br />Numbcr: Expires: <br />--l certifo that in the performance of the work for which this permit is issued, I shall not employ any person in any manner <br />so asto <br />workers' <br />become subject <br />compensstion <br />to thc worters'compensation laws of California, and agree that if I should become subject to the <br />provisions of Section 3700 of thc l-abor Code, I shall. forthwith comply with thosc provisions.. <br />WARNING: Failurc to secure workers' compensation covcrage <br />civil fines up to one hundred thousand dollars ($100,000), in <br />ls and <br />thc <br />3076 interest and fees. <br />( <br />LICENSED CONTRACTOR <br />DECI-,ARATION <br />I hereby affirm undcr penalty of pojury that I arn licensed under provision of Chapto 9 (commencing with Section 7000) of Division 3 <br />of thc Business and Professions Code. and rny license is in full force and effect. <br />License Number: <br />f^-r-^nra-. <br />W <br />I hrcby aflirm undo pcnatty of pqjury that th6e is a snstructiotr l€nding ag@cy for thc pcfomce of thc wort for which this psmit b <br />issued (Se. 3097, Civ. C.). <br />Lnds's Ndnc: <br />Lender's Ad&ess: <br />A.'LICANT DECLA TTon <br />I herdryaffirm under poalty of perjury one of the following declarations: <br />Demolition Permits-Asbcstos Notification Federal Regulations (Title 40. Part6) <br />-Required <br />lrtter of Notification <br />_l certi& that the federal regulations regarding asbtos removal iue not applicable to this projd. <br />information is correcl. I agree to comply with all City and County <br />authorize reprcsentatives of this City and County to enter upon the <br />above mentioned property for <br />Applicant or Agcnt <br />Permitec narnc f\ <br />state <br />Vfttv{tA <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 />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 A,\ .t - 0t <br />FINAL \ U\trSV'A btt4ry/Yl <br />Notes, Remarks, Etc \ <br />-, <br />t. <br />=N t/)/r r.eIA(q