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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE COMMENTS OWNER BUILDET DELCAf,ATION
<br />I h.eby rtnm unds pcnalty of F4rr,Inar I d crcnpt from rtc Conrturor' Ltcns L!* for rh. following ltsn (Se 7011.5
<br />Busi@rs und PDtc$io. Codc): An, Ciry o, County shkh rcqlires a lemn ro .dnnrud. ,lrd. imp,orc. .bmlhh or EI,!tr rny
<br />slNtm, prior ro ils is.trucc, llso Eiuircs lh. .pplicer for fl.h pcmit io fih a siSmd saLmnl lhll lE or shc is liensn p! ulnl
<br />io lhc novjsioos 6rrE Cqthdn r Li.co*d Law (Claprer 9. Conoe.cing wilh Sccrion 70fi) of Division 3 oflh. Busincss lnd
<br />Pofcssions Codc) or lhll lrc tr slE n c*q)l lh.EiiDn sd rlE basis for lh. .ll.!.d crcnplion. Any rhloliotr ofS*lbn 7011.5 by rn,
<br />lpplicanr for ! n mn slh.i{rri tnc spplio lo a cieil l,cnalty of .or mrc rhM fivc hudEd dollos ($500)
<br />-1,
<br />as ovncr of lhc FsFny, o! my cdpht.cs with wagcs {s rhcir sL onp.nsalion. will .b lnc wlk orn dE turd@ ir ml
<br />inrcn&d or otr€rcd for slc (Sc.7044. Ausirss snd Ptofcsions Cslc: Thc Coitrlclor's Liris ti* der mr apDly ro ,n 6wna of
<br />lhc pDFny wrb hiil& or in{mEs if,@n. ud who &as sh m& hjm\cu 6r hc&lr or lhrcugh hh o. ts ovn cmplotr.s,
<br />pmvidcd rhd s!.h iq,mttu, s E hr inlcid.d orotu lor slc. ll trEE. tlE tlildiu tr i,qmer issld*irthotuyw
<br />of conplclion. dE Own r Auihd wil tqw tlE bu{hn ol pbvin8 lh{ lE m $c dn d hild or irpor fi. pbrny for t,E 0!qns of
<br />-1.
<br />&i owmr ot rht Iron ny. ,m ciclusircly conrrsrinB *irh lian*d mirGros ro dnsttur rhc nolrt (Se. ,044. BNins
<br />lrd Profcssnn Codc: Th.Conlmlols Li..nsc tiw dcs nor optlyro anowkr olproFrly who builds or iq,mvcs lhcron,
<br />rnd who oflhcrs for slch nbjccrs rirh , Conld.torls) Iiccn*d ,us!a ro rhc Cr,nh.toas Lirn* lrel
<br />I rn'.rcmnr unJ.r S(ri.I &PC l'orlnisrcas'n.
<br />ITOTI(EIS' COMPENSATON
<br />DECLAAAIION
<br />I hs.l,y artrm ur&r pcndly oI pcjury om oalhc followinS dsld ioDs:
<br />Ilrvctullwillmrn r'nrCc rfi.dcofcon\cnr lo sclf ln\url,, w.rtdJ compctrsttotr. us nmvid.d lor bysccrnnr:1700 ol rhc
<br />Lrhtr (i r. f(tr rhc p.rfornrn.c of rhc w.rl f.r which rtc psntil n $kd
<br />Zylmvc rnd willmri rir worlc^ comFnsdion insufln c. d\ rcquncd hy scd ion rrm or rh. Lftor (hdc, tor rhe p.rlorromc ol
<br />P)this p€mn n is$cd. My uorkds' sqrndion in lM. cMtr .id polay numbcr @lc(
<br />Z
<br />I enify $al ii rhc r..lorn@c. of$c worl for ehichrhi\ peinir is isslcd. I sh,ll.ol cnploy..y p.6on in any mmr
<br />m s lo 6.{om subiel lo th. *ortm snqrcnsli.n l,ss oac3lifomio. and .grcc lhlr if I stnuld ltotr subjccl lo tk
<br />wo*.is' omp.ns.tion prclisions of Scclion 3?00 oi lhc tjtrr C.dc. I sh,ll. forlhwith compl, eilh thos pmvhionr..
<br />WARNINC F,ilurc to s.urc work tr conp..sarion sv.6g. ii unl,wtut. and sholl subjd m cmploltr lo oidiul IEMhies lnd
<br />.ivil ,lncs ut io oB hxndrcd ihouund dollrs (31U,,m0). in addhi.n ro rh. corl ofcompcn*lion. dlm8.s as pmridcd for lhc
<br />ulllsru_qQlirBAclaB
<br />Dlrll.lts/UloN
<br />Ilrcrcby.innrundcrpcnrlryoIrErjuryrhirIrmliccncdu.rpn'visionolChrnlc,9(connmncina*ilhSsrirn?(xm)orI)ivisi{,,-1
<br />of rh. ax\incl\ md Ptuf.sions Cod.. dri ny li..ns. is in rull in( Md clf..r
<br />C Cza 7??r7a
<br />COIIiIBUCIII,INIINDING.f,GENCI
<br />I turcby rftinn und.r Fn0lryolpcrjury rhlr lherc h ! <,nsrrucriotr lcodin8 !3crcr lor ltc pcriornurcr oirhc *orl lor $hi.h rhi\ Fmir il
<br />issucd (Scc. :10S7, Civ. C )
<br />AEELICANI.DECLAMIION
<br />I ffiy nfrm unds pcDliy of pc.jury om of thc lollowing d.clmiions:
<br />Dcmlilion Pcrmils'AstEslos Nolificalion Fcdcml RcEulations (TilL.l0. Pun6)
<br />-Rcatrtcd
<br />blr.r oi Noliftrdhn
<br />Z -l
<br />cs! ity ihlt rlE fcn El rcguhrions rc8&ding asbcslos Emvd m ml .t{,1i.!blc lo lnis proFcl.
<br />I c.niry rhd I hlvc r.ad rhiq rtplicnliof, md nrt rhtrl rhc .tnrc inromlion k coftd. I .gG lo sr{,ly wnh aI Cil, and Colnty
<br />irdinanccs rnd Srrrr lrss rhring b hildin! co!{dcrn,n. md hcrctry 3urhorii. rrpn\cnrdirr\ ofrhi\ Ciry a.d
<br />h,vc tunii,,rd !n'p.ny ln. i'r\rcri,)
<br />Amlica or Agenr SiBtururs_Y-_I g
<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 />Rouoh Ductwork
<br />Toilet Room / Clothes Dryer
<br />Residential Ranoe
<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 />Meler Release
<br />FINAL t//rc/*'b??rya v?F=t
<br />Nqtes, Remarks, Etc.
<br />/*32 Vz -d-fr,"- /Ds, ^",
<br />c.T- C,/.2/ /*t)44
<br />@-"2<azz7-tn
<br />ID/SIG.
<br />Vents
<br />Other
<br />W
<br />L.ndd r Add{s'
<br />-
<br />I
<br />f- - ---T------
<br />II
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