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MECHANICAL-INSPECTOB RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OW]\IER DUILDER DELCANATION
<br />I hcrcby .ffrm urhr pcDaly ol pcrjury th&r ! u dcn,l fmd rhc Co.t a.loB LiccnF Llw for rhc lollowinr @en (Str.7031.5
<br />Busincss !d Profcashn Codc): Ary Cily or Counly whi.h rcqliEs . Frnjr lo @.!rru.L ahr. iq,Nvc. d.mlish or E .n d
<br />.rocrw. rior ro irs i$uarcc. al$ Eq{ircs $c .pplt! for sEn pcrmjr lo fiL ! si8md sraIcmnr rh.! lE or she b lienscd lumd
<br />lo lhc rmvhions oflh. ContBclols Lic.nsd Llw (CMpi.r 9, Conmcftin8 wilh Sc.lion 70oo ol Division 3 of thc ausin.$ r.d
<br />Prci.sior. Cod.) or rh.! lEd1lE h dcrDr dEEfromlnd E bcsis lorlhe rlkS.rl .tutr{,rior. Any vioLrionofssrion 7031.t byliy
<br />lpplicanl for a !.mil subjmh thc lpplica.t lo a .ivil tlc.alty ol nor mE thd ,ivc hun.!.d dollatr ($500),
<br />_1. !s oqncr of rhe l)mlrnr, or my.dlloyes *ith *l8.s cs rn n $h comp.niarion, will do rlE M* .rd llE srtrrw is mr
<br />intdrlcd or oilcrcd r.r sl. (Se 7044. surincii &d Prof€ssiois Code Tnc Co.treror's Ltcns Law docr nd artly lo rn 6wnf of
<br />lic pollcny who hlitls or impmss drdfl. ad sln d.a Mh *o* himslaor lEcclf or lhmush hh or hn oqn chployei
<br />l,mvid.d thal such impmEmnhmmli c.d.d or o,Iftd lor sh. lr. hoEq, rlr hoiuing m ilrpEwtufl b sU wnhi. o.e ,rd
<br />olconpktb.. th. Owmr Blildd willhaE lhcbu cn olpovine lhd h. or df, did ml bnild or iipmw fic FDFIy for tlE lu.poEof
<br />l. as ownf oa Inc pEFny. ancxcllsivclrconrrrcrin8 *irl lircns.n conrradon b mnsrur rlE pmJsr (Se. ?044. Burimrs
<br />lnd Etrfssbn Codc: Thc Conlrclols Liccnsc Lrw docs .or rutly b d. ownc. or potEny who builds o. inprovcs lhcrmn,
<br />,nd who .om@rr r.r t!.h poicr! wnh a CDnr6cto(O liccnscd plsunt ro rhc Co.lncror's Liccnsc Ljq).
<br />I rui. rtl u dcr scriioi . D & t,( nnlhn rrr$D
<br />t)nrr ()$n.r
<br />lcoarE8s:lQuflNsAroN
<br />DF,CI ARATI(IN
<br />I hcrcby !fin'n und.r Fnahy ol F.jury oft or rh4 follo*ine dElrdrionsl
<br />-l
<br />hrtc aBl *illmiintri,r. CcnifEarc oiCon{d ro Scl n<ur. ktr lo.kcn .o nlxns0r ion. $ amvilL\t to r by S.d ion ST(x) o i l hc
<br />tih.r Codc.lnr rhc p.rfnran...lrh. {.rk ror *hih rk pcrmit i\ is\ucd
<br />!, n*" und * r, ,,.'n,u,n *orkcr' comF.nsor ion insua.Ec. ,s rcqun d by Sccr ion l?m of rhc t,nor C.dc. inr r hc !E iornrncc of
<br />Mywortcm mnDcnsalion insu$mc mricr Md rolicy numbcr m:
<br />X I 2-
<br />I ccdiry rh i. th€ p.rrormftc.rrhc work ror whkh rhis pcrdil is i\sued, I shallnor cmtlo, lny pc^on in my tu.nd{i !{ ro bc.nm subj$l lo lh€ so*crs compcn$lion hqs ofc{lifomia.
<br />"nd
<br />a8N lhlt if I should b.{om subjsl to lhc
<br />so*c6 .orycnslion,n,vhions ot Scdion 3700 of ttc t hor Codc, I shrll. fonhwith coq,ly wiln tho* pbvnioni
<br />WARNING: Failum b scur wo .n .omFn{rion covcBge i\ rnh*tuI. a.d shall \ubrc.r .mplo'tr ro diminal ,r.'lrix and ,
<br />civil 6n.s up lo onc hunded rhouend dollrs ($l00,mo). in irnnr io rhc co{r ol codp.n\ ion. drtugc\ a\ pbvidcd lnr rh.
<br />n .r.< ind ir.mv ( rNr
<br />L lg 2-o
<br />LICINIEILCONITACII)B
<br />PECIdBAIIO!
<br />I hcEhy rffsm u.d6 !€!.lry of F.jury thd I u lkrtucd undcr pmvision ofch.oo 9 (@nmeing wnh S6rio. 7000) of Divkion 3a247 9zb1frH41'hq Ict0CL
<br />\ ts l'?-o rYgEat Lo+||tu<'T
<br />caxsralcrloNrDll2tlri_&aENqr
<br />I lrrcby rfiirm ufrhr Fnilry ofFqurr rhd rh.r. i\ a.on{tucri,n kndinE rgcn.t tor Ihc p(lbrnhftc.frh. rnrk i,r ahi.h thi ff,mir ir
<br />nsucd rsc. l(D7. Civ C r
<br />AIILI(ANLIIECITIAAUOts
<br />I ltrb, nnim hdcr l)cnally ofI'cdlry onc ofrhc rblb*in8 d..ltrrdn,ns
<br />Dc'frniion Pcrmi( Ashc{os Norificarion Fedcral Resulorions (Tirlc4r- Pan6)
<br />-RcqtrncdkrlcrolNotirKdi
<br />r
<br />-lcc
<br />ilyrhrrrhcfcdcfllrcSul,rioDrElddin8$h-no\rcnn'lrlr. or rplh(rhlc b rhi\ pniLir.
<br />ef.cn,ry rhd I hr red rhis rrrli.rrio. ud rrrrc rhor rh. atnvc inininurion i! corccr I lsrelo.onuly$nhrllCntlddCornrt
<br />onlintrtres ond Sratc L€qsrcbrinslo buiiing rndhcrchyaurk,i-rcl,csnt ivcsorlhisCnyadCoutrl,tocntcrupotrtnc
<br />abovc mnrioned pon rry for insp.ction
<br />/Applicanr or A8cnr si8mtu zlBlzb
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />lvlisc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />Smoke Detectors lnstalled
<br />Rough Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Ranqe
<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 />Ro ugh Mech.
<br />Final Test
<br />Meter Release rl rl
<br />FINAL 2 1
<br />Notes, Remarks, Etc I
<br />Appliances
<br />lnsulation
<br />.\2KTY)67-+t tr7
<br />o, lhc Blsin.sslnd Protcssions G)dc, dd myliccns is in tull lora and c(ccr
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