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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUTLDER DELCARATION
<br />I h.eby am.n lndcr llcdll, oa pcrju,y |har I e crcrry fed t C.nr,cro*' Lic.ns L€* aor lhc followi.s @en (Se.70:11.5
<br />Ausin.$ lnd ftoresrion Codc): Any Cily or Counry which rcquircs a tf,rmi to onsrtocl aitd. ioprow. d.mlilh or Epln .ry
<br />srrucrlr.. Fhr ro ns issuarc, ats r.qun6 rhc lppli.afl for $ch pcmi ro lih { sigEi nftmnl th lE or she h li.cncd Pursurm
<br />lo thc tr.viri.B of lh. Corhclols Li.cnsd tis (Ctullcr 9, ConmncinS wilh Scclion ?000 ot Division I oflhc BusiDcts and
<br />PmfcsshnsCodc)orthrtlEorshchcxcmprrh.rcfromandrnchasisforrhcalLscdcxcqnion,Anyviolalionofsclhn?0rl5by!n,
<br />qTlicdnr for s pcmir subjdlr rhc lnpli.mr r a caril Fnalr, ol nor mE $d nv. hundrcd doll,rs (3500).
<br />-1.
<br />f,1 owE of $c pFFrly, or ny cnployes wilh *!8.s * llEt $lc rcmpcn*lion. {iI do tlr $ott .rd dx eulw is ml
<br />inleldcd or ofcrcd for sL (56.10!1. Bliituis aod ftofc$io i C6dc, Thc C.nhdol s Liccnsc kw do.s nol apply lo e ourcr 6f
<br />rrE ImFny sho hild... inpmE tlEm( !d whn d(B sh m* him.lf or nc*lf or llhugh hh or her owo cn'phyes.
<br />providcd rhsr so.h inprowBnl3 @ mr i.rcnrhd ororrcrd for eh.li howcxi tlE trildin8 or imprcemnl is snld *irhu on. rs
<br />ofcotr tcriorl rtE Osftr Builhr eill hah itr htdc, of ,mvi.g thd lE or sh. dd ml build or impmE th. I'trtEly ao. tL pqb. of
<br />-1.
<br />asowturolrhc pn,I)eny, &r.r.lusivcly.ortrdcling wih lkcns.d contrrcloslo consrruct rl* phFt (Scc.704:1. Bu\ift{
<br />od hDiission Codc: Thc Conklcrols Liccnsc Lrw docs ml omlr r. an owncr ofpor.ny tho hlilds or impovcs lhcreo.,
<br />and who d,nr@rr lor s!.h p6ir( wirh a ComEcr.(rl licn*d ,)trsulnr ro rhc Controctols Lisnsc L!{).
<br />-lanrxcmfl
<br />u.der Sei0
<br />-l
<br />h{vc .d will minrain o C.nificarc of Cons.nt ro Sclf' lns!rc for worls oqanerion, .. pmridcd for by Salion 1700 of lh.
<br />Libo. Codr, lo. ih. p.rlo,mr of thc worl for *hi.h Ih. Fsmit is ksucd.
<br />_l hlvc !trd Nill minrain eorkc^ comrcnssrion insonncc. .s rcquircd by Setion 3700 oa tt khor C.dc. aor lh€ PcrfoMe of
<br />lhc wrk for whth lnls ,.rn r is hssd. My *orkos ompcnsrrion in$rme cuio !n polty numh.r m:
<br />-l.cnify
<br />rhar in $c pdfornr!.c.frh. work lbr *hki thig lonn is Gsucd.l shallnol cq,loyany pc*o. i. d., m.n.r
<br />s ,. ro b..om subFr ro th. *orlcB'comFns.rion l"*s of Cdifomia. $d aB@ rhat ia I shduld b.com subjFl lo l,E
<br />worlcB orp.n$!io. FovisioN ofScclion 3T00 oflnc bbr Codc.l slull. fonhwirh coq,ly wirhrho$ pmvisions
<br />WARNTNC: Friturc ro slrc worlcB .6np.nsdio. ov.ne. h nnllsful, snd shlll subject an cnployc, ro oininal Fnnhics n.d
<br />ro on. hlndrcd douidnn d.ls. ($IO0.O0O). in addilion lo lhc cosl of conpcnsdion. dumBca a$ provid.d for rh.
<br />sdhn 3076 of rhc L{l,r Gxle, inbrc$ ald dno.rcy 3 fei
<br />I lEBby affrm uode. Fndly of pcriuy lhrl I m liccnsd unds pmlision of Chapld 9 (comrcinE with Setion ?000) of Diehion l
<br />oa lh. Busircss ud Pofe$ioni Code. dd my licen* i! in tull loEc srd cf,ccl
<br />I heruhy amrh und.r Jrnrlryorp.rJurythd rlErc is. connrudirn hMin8 ascmy f.r lhc Frloimtu. or'hc work fo. which rhn lcrmil h
<br />hsucd (Scc.109?. Civ. C.)
<br />ATTUCAN:LDTILAM.TAN
<br />It*m$,nfllnnu uN.,lryor!.Uuryotrcol rhcnnbBin8dslanrrionr:
<br />l)cnElirion l,crmils A$c{os Nori6carion Fcdcral Rcguhr ion\ (Tn[ .rc. Pd6)
<br />Rcquncd hnd of Norifi(irnn
<br />IccnifyrhrrrhcLdc ltoBulirionsrcsmnir8!!n r.rrcnn^ali.cnorlnll.!hLlorhi\pmrlrr
<br />I c.nilirhd I hilc rc rhi\ qrtlicnrn{ nlld {.rc r lkr rhc nh)!. itrLnr i,,n ir.om.r l aErN i, co rfly tr irh rll Ciry nd Coutrry
<br />ordinlkes and st8rc Liws rcl&rin8 lo hfcbt.urho,tc rcprcsctrhrivcs olrm Cirylnd Codnry t, cnro upon rh.
<br />rli,r nrnrioncd an'p.nt for
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rouqh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Ranqe
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />Openings
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.qlfl$Tu 9'[&I
<br />Final Test r. I )r
<br />Meter Release
<br />FINAL tpilbtt4T f.?7 )
<br />Notes, Remarks, Etc.
<br />lnstallation
<br />-Tr--r
<br />troSf,EBL:cottfENrarxa
<br />DECLANATION
<br />I hcrcby omrh undcr pctulty of Nrj!ry onc ol rhc atnk,s in8 deldarions:
<br />D.lc: ppli6l:
<br />...,."",.*
<br />T
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