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APPROVALS DATE ID/SIG.COMMENTS
<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 />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Range
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Fire Damper
<br />Openinos
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Rough Mech.
<br />Meter Release I
<br />FINAL x/9/-/,4H.;, <t'l /ecr' fl
<br />Notes, Remarks, Etc.2/r-6/+84",/ --*2n/)
<br />OWNER BUILDEf, DELCARATION
<br />I htrcby.ffrm ullder lcfllhy of p.iury rh l m.ieryr ten rhc Co.rracloB Licens L€* for fie folloPi.g E.s. (Sc.?Oll.'
<br />Ausincss sd Pbfssion Cod.): An, Cily o, Counry wtth ElliEs a Fhil lo consltucl. all6. imptorc, d.mlish or rll.n uy
<br />s|fudm, Fior to irs issw.. i&. rqoiEs lhc {ppl,cul for Mh Frmit lo filc ! si8rcd {al.rcnl lltrl lE ot sh. h lkcncd PusuMl
<br />ro rhc povisions of thc ContBctols Li.ersd ko (Charrr 9, Con@Ein8 wilh S.ction ?m0 of Divi.ion 3 of ihc B8incs .nd
<br />PEfcasions Codc) or rhrr h. tr ilr is cx.mDt rh.E6om arn rlE hdsir for llE sltg.d crcmPrion. Ary vioLtiooofSelion ?011.5 by dy
<br />apnlic.nr lor s Fmil iubicds lhe q,r,licant lo s cilil lcnalty ot not turc lhd tivc hundr.d dolb.s ($500).
<br />-1.
<br />as opM of rhe ,'er.ny. o my enlploFr sith wag.s s rhcn sb omrctudion. *iu iki th. wk trid 0E nmrE i5 mt
<br />intod.d or olT.ci lor eh (se.7044. Business ond Prcfcslions cod.: Thc co.hd('r Uc.ns Lr* do.s ml .plly m e owmr 6f
<br />rh. pmFrty who hrird! m i,Fos rhd@n. od who ds sh hrt hi6..lf or hs*lfor llhlgh hir or ho own enPloyccs.
<br />potided thll srch irlrov@nl3s ml htcndcd or of.r.d for src. If. hoM. d. l,uilding ot inP,@r.l t sld wtlhinoft Fa
<br />ofotr{,hlbn, rlr O*M Buit r wiu leE 0E trr&n ofpmvioe dd lE or shc dn d tlilt or inP ot ,E n qdy for l,r PortEs oa
<br />-t.
<br />m owmr of rhe ropcny, an.r.lusirly contE rins wirh liccnsd ontndon ro .onsntrci llI pmjccl ls(. ?o44. Blrinss
<br />a.d EDhsb. Codc:Ihc Conklclor\ Liccnsc Lsw doer not dpnlyto,novnct of DrcI.ny who huilds or ihpinvcs rhcr.on.
<br />r qho snlmcrs for slch p(rirk witl a Co .a.ro(s) lic..sn l'ucutrl lo thc Coflreroi\ LieM llw).
<br />-l
<br />amcxcfrfl lndf Serio B &PC lbrlnhrclw,n
<br />IOXAESESIMTENIAITON
<br />DECI.AEAITQN
<br />I hcrcny omih un&r pcMlty of lcrjury orc of rh. fouoeinE dekErk,Bl
<br />I hrvc n wr ll nrinhin r Ccn ifrorc oa C.n{nr tJ scll ln$r tur sorkcr\' .o.rlEnslrio.. as pmlidcdforbrsccriotrlr0oollhc
<br />uhJr C.dc. lir rhc p.rf.rrroDcc o, lhc uork tur wh ich I h. Firni n i\suRt
<br />-t hrw lnd eill minl,i. sork6 .or{Emalion insommc. as Equned b, Ssrion 1700 of rhc l,hor Codc. lor lhc lc.ionMrcc of
<br />ID work for ehi.h rhh Fmir i! Lrsrcd. My wort6 onpcnsalion inslrane cdic. .rt p.li.y numb.r ac:
<br />Policy Nunrtcr:-Eil
<br />-l
<br />ccniry rhar in rhc r.rforrore ofthc wort for which lhh pcrmit ir L\lkd. ! shall nol c'nPloy any Pcron in aoy n,nmr
<br />s N ro h..om $tjccl to tlr worterr @6p€n$rion !a*. of C{liloni!. {nd tr8rec thlt it I should trtoiE subixl lo lh.
<br />workcs comp.nsalion Imvisio.s of S.crioo l7(r0 6f lhc tln r Cdlc, I shaU. fonh*nh conq y wirh llx,* pmvbions
<br />WARNINC Failurc b scurc *olkcrl mnrp€trsri.n .ovcrusc i\ unlawtul. ,trd shall suhj$t in cnplorrr ro dninnl lEmkts md
<br />cNil li.ca u! ro one hundEd lhousrd dollaB 100.000). in sddnion ro rh. cost of cohl,cretion. dln[lcs as Pruvid.d for ln
<br />S..rn'n 1076ofrhc Lrh, C'dic. irrcrcsllnd
<br />t lzzl.t8'
<br />I hcrch, umm uRL, pcnalryoll.llury rhd I rd liensn und.t Pn)virion olChlplct 9lcomfttuinB *irh S(rir ?0lO) ol Diri\iir l
<br />ol rhc 3!rircs{ md Pn tsio.\Codc.dnd nylicrn* i\ in full fi .t $dcllc.l
<br />2 t17a I t t ?
<br />€/r z )tv-
<br />I lErby llttrm undcr p.nrlly ot rcrjory
<br />kstr.d (Se. 3097. Cir. C.).
<br />fl.rhn LndinB r8cnc, ror thc p$forn@c of rhc work for *nich rhis Fmn iq
<br />L.ndcai N3ft
<br />-
<br />l.cnifyrhd rhc fcdcnl rcsuhtion\ rcsudin! !!tt{osrcnr,vddc nor lPplictblc h this Po,ccr
<br />MECHANICAL-INSPECTOR RECORD
<br />Grease Duct
<br />Above T-Bar
<br />Final Test bndcls Addrc$:
<br />-
<br />r pt't-tcrfr iiiiliip,rixrn
<br />I rly.$, alltnr undcr Ntrilry.fpcrjury.nc otrhc tollosins dc.l rdn,ns:
<br />Dcmnii,,n Pcnnirs {h.no\ Norifi.ari,rn F.rlcrnlRcsuldi,rn\ (Tirlc l0.l'an6)
<br />R.quir.d Lcncr olNotili.diur
<br />T
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