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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE tD/stG.OWNER AULDER DELCARATION <br />I hcEby.firm undcr peMlty of pcdor) lhr| I !d erenfl fion rhe Conudou' Ltcnsc Llq for lhc followi.S EMn (Sc.7o.ll.5 <br />BlsiB. ,rd Prlfcssion Codc): Any Cily or Counly *hi.h rcq{iEs ! IEmi $ .o6rruci. {ltci improw. &mtish or rcprn any <br />slMrnE, ri,r ro irs ksu.tuc, ols rauircs rhc aidicair for slch ttnDi lo fiIc s si8rcd slllcm tnll lE or ihc h lkmkd Iuruanl <br />lo rhe Fovisn,ns ottu ConrBlols Lieicd Lw (Ch!pt$ 9, Conmmins qilh S*lion 7fi10 oi Divhioi 3 oflnc B!sin.s. and <br />tmtc$ionr Codc) or th lE or3h. iscr.mpt thcrdo'naId rhc bsls for llE alhled cx.mprhn. anyYiohlionofSslhn7011.5byrny <br />applicrnr aor s lcmir subr.cls lhc applka.l loucililpenalltofnot mt the ivc hundrcd dollrs ($Jm). <br />-1, <br />!r o*nr of rhc FnFnr. or oy .nplorEs wilh wa8cs as lhcir slc com!'cnsdiotr *ill do rlE wo& and rh. inclE is mt <br />inlo:d.d or ofi.Ed for $1. (5e.?044. Blsires ed Pmfessions Code Thc Co.r,rctol s Li4np llv d.cs nol 4,ply ro s owm. of <br />rlE pmFny wtn hrilds or inpoB t.Mtr &d wh6 ib6 sEh Mdr hinself or ncrclf or lhtuugh his or hcl own .nphy!.s, <br />poridert !h&r sEh irlmE s.ls e ml inlc cddoll.rcd lor eh.Il rsErd,lhc buiHinB o, i'r{Ntm h$ldwhhinomFe <br />ofon{llcrh'! rhc Ownf Bujli:16 will hrrc rhc hrdcn or Fovi.g thd h. or she dn d buik or imrr.w ['c pmlrny for ln. pu4bs ot <br />t. es own$ or lhc ,,$.ny, m cxchsivcly anrrading wnh lic.n*d co.r6.roE ro @Nru.1 llt ,,mr.{l {Se. 7044, Buiims <br />lrd AofBsbn Codcr Ttc Conrmlork l-i.c.s ttw do.s mr +ply b o owncr of propcny *ho l,uilda or improv.s lh.rcon. <br />trnd wno .onhcr. for sch rmjccis sirh a ConrEb(9 liccnscd rruMr ro rh. Conreltr ! Lt.n* L3s). <br />-l <br />fficrcmpt undcr Scct <br />Irelc: _- O*Er:_ <br />WORKERS' COMPflISTT(IN <br />DECLAAAIION <br />I hsrby 1ffirn udct rerulry oa ptrjuy o* ollhc foll.wi.B d(lmlion.: <br />-t <br />h!!€ &d will minmir 6 Ccnifrd. of Co.enl ro Selr-lnsurc for wort6 mnpcns ion.I Fivilcd fot by SdIion 3700 oflk <br />Lihor Codc. for lhc pcrformne of rhc mrt for *hkh lhe ocmit ir hsd. <br />-l <br />havc ud will mainrrin vorkcis .oq).ns io. insuraN.. as r.quied by Sslion 3700 of rhe ljb.t Cln . for lhc ,sfottucc of <br />rhc wor* for {hth lhn pcmn k issucd. My wd*4 ompcnsion irsr0ne cMi( !,n PIi.y oomb.r m: <br />- S{-"+t€ F,r-,Ic.L 22, <br />-l.cnily <br />rhsi i.(hc p.rlorflncc olthc *o* aor vnict this lErni h nslcd, I ihall o.r cmploylny !.mn in rny oEntur <br />s !s to tEs'm sub;rr ro rhc &lids'coq)..sorbn hwsofcdlirornh, and a8@ rnar ifI sholld h..om bj.ct ro tlE <br />wortc6' .o'npcnslrion prolnbn! or Serion 3700 ot rhc tibor C.dc. I sholl. fonhwirh shply {irh rhoc tDvision!. <br />WARNINC: F0ilurc to w!rc so*cn' conrFnsllion c.vcmac is uiliwtul. ind shrll subjd !n cmplortr lo oida!,| FMnhs and <br />civil nncs up lo om huDdrd lnousnd dollus ($l ion. damgei as lovidcd for lhc <br />sccrnr 3076 0r rhc Lihtr codc. inrcrcsr 8nd !rqlpl.orrI <br />ur;lNrr:DroNt&tc.&a <br />DICLABdIIgN <br />I lrcrcbyrlftnru dcr pcnallyofp.!urtthnrI nli.c0klundcrtn'vNiuIol(htrcrI(conntncingsirhsc.rintr7(xx])oll)ivi\i,r:1 <br />oi rrtr Bu$trcs\ rtrJ Pmfc$iorNG'dc. itol mr liccn\s t in tulllnre4iclrc.r <br />.q--2r)t >7 b <br />^," q<)q-z.olK_,"* <br />caNi[8ucu0l{"L[!DlN(i-[a[xl;l <br />I hsrcby !fiirm undr Fnrhyofp.rjury rhd th.rc t r con$d.tion lcndirs rscncy ro, rhc l*riomtsn.c oillt wo.k for shich rhh P.nnir i\ <br />hsucd(ss 3ir97.civ c ) <br />A.8II.]CANLDIIIAIAIIOII <br />Ilanb] lunnrnd$ pctrrlry ol'ocrjury.trc ollht folL,,*inr dNhrrrn,n\: <br />I).nn,liriotr Pcflnir\ A\hc(o\ Norili.rrnnr F.dcrul Rcguluri(r\ ( rirl. J0. Prn6r <br />-Rcquncd <br />Lcud uf Nurili.rlinr <br />-l <br />enif, rhd the lcdeal EellnrioB Egarding 8b..los aeral aE nol lpplicrbE lo lhir rojer <br />_l.c(iry rhni I hah Md rhk.ppli..rion0 sratc rhar tlrc.b.w informrion is.orer.I4r< lo 6mplyvith !U Cilyana Couni, <br />ordinaftcr and Sr!r. Lrws rhrine ro hcrcby.uthtria rq,r*nrarivcs oarhiq Ciryatul Coutrlyto cnrcr upon rhc <br />rh,vc nrdri(nrd F)n ny <br />Apdi*nr or ABc SiSnau <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 lnstalled <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranoe <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 />Meler Release lx <br />FINAL t"747 *,viy) <br />Notes, Remarks, Etc.W$ lzLtot\*- oK-. <br />COMMENTS <br />lr .a. N.ft: <br />- <br />L.ndB r Addrc3.: <br />- <br />-------r-------+- <br />tt <br />I <br />=