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APPROVALS DATE ID/SIG.COMMENTS OWNER BUII-DI.JR t'UI,CARATIoN
<br />Ih.rchyrllt rndcr lcMlry otFjory rh lrr.icn,pr li,m rhr G, B.hn! l-i.cn{ Lw nn rhc nnk'sin8 r.0nD (S.r7011.5
<br />Bd\incs\ trft| Pofc\\t'n CGl.): Atry Ciry or C.um) $hi.h rqdtr\ r ,rirnl n' con(dcr. rlr$. inrl,orr. d.nnlish or r1L't .'ny
<br />{ruduR. tritrt, n\ ir\unn.c. rl{ r.quncsrlr l'lpli.rir tur su.h ltnnirr,,ilc r \i8md sldcn(fr rhrr hcor \lt i\ li(itcd pur\or r
<br />ri rhc p0visi.n\ ol rh- Contrrcnr\ !-i.ci\cJ lrN (ahalrur 9. clnnni.rnr! w,th Sc.ri( 7(Xxr ol Divi(nnr ll of rhc hNiN\\ rnd
<br />Pnncs\nnisCodc)orihxrhcorrhciscrcnrtrthciclirnnodrtEhrrhLrrhc!llcgL'dcrcnrprion.A.tri{nrrionofSccronT0ll5lryrn,
<br />nptli.rnr hrr n nnil suhtccr\rhc apnli.rnr ro rcivilpcnnlrloinor mncrhrn lnc hundrcddoll&\ l55U))
<br />l. os owner or lh. toFrly. or ny employes with vr8cs as th.n sb compcnsetion, sill do rhc so* lnd rlE {ruI!rc is q
<br />i cndr{ or o,tcrcd for ek (Se.7Og. Bnsinu* 6.d PYolc*bn. Cod.r Thc C.nracrol s Liccnsc &w d.cs nol lPply 16 n own r 6r
<br />rhc lmlEny who trildsor impmws lhcen, stn wb docs schs himiclfor h.relaot $sugh his ot hcr own cn[h].cs.
<br />provid.n rnll such idpmrcmnh d mr hr.nded or 6,I!.td for {&,lt hoecm.llE huildinS or iryrcEmnl G sld vi'hii ot ru
<br />ofonplcrio.. ln. Owmr Builds wil hove lh€ bqrd.. ofrr.ving 0In hc or slE dii n,l t ild or nrrmE tlt pDtEl, for th. purls* of
<br />{lc)
<br />_1. (\.rvNrol rtu,'Nrfi!. rmc\clu\ivclyco0rrrcrio! sith li.ctr\c.lcoftrcttr\ t,.od{tu.r rh. Dn)lc.r rscc 70.1-l.lruNncs\
<br />iftl lhni:*in(ixl.'rhcCoik&kr'sli.cn\.t-rsriocsfnrrftnyn,r otrner.fpxipcrry*hohrild\ori'llrovr\rhc o.
<br />rnd trho contr.l\li,r $ch tnolccr\witha O)nlracl.tr(sr liccns'l pu^urrr tr) rhc Contrtrn'\ I-'c. scIitw)
<br />I amcr.m.r undd Smr B & l'C f(tr rhi\ runri
<br />IITBtrNELCI}IISENIAII()N
<br />DECI ARATION
<br />I lrrchy lffirn rndcr Fnalry of Frj!ry onc of ih. lollowing dcclf,rdhns:
<br />-l
<br />hNr aM * ill minrrin ! Ccnincr'c or Con\cnr t' sclr ln\urc n *ulkc^ .onrpcnsdi()n. 3\ providcd fnhrsccrtnr]Tmorrh.
<br />tihtr ctnlc. for rhc D.rrbnu.ccolrhc sorl,ir$hi.hlhc pcrnil i\ i$u.d
<br />_l hlrc Dnd * ill Euinrain wortcts .orhpcnsarion insurdncc, os mquind hy Srclion 3?U) of lhc L,bor Codc. to. r& l.m,.m. or
<br />rh. work lor which ihis p.mil is issual. My worr.m .orq.nslrion insuratra oFhr ud F,li.y fllmbcr rc:
<br />.n/,
<br />-tenilyrh
<br />in rhc r..fomM or rhc wort for which
<br />'hh
<br />pcn t h hsued,I shru not cnrphy lny i'cmtr ii lnyM*,
<br />so a. t. h..oB subjcd to thc wortm onpcnslhn llws of Crlifomiq ond asE lhal if I should b.<orc 3ub.id lo tlE
<br />workd( ompcnsolion pmvisions of Sc.lion 1700 oa th. L.hnr Codc. t nElL fonh{irh oq,ly *alh tl5* tovisions..
<br />WARNINC: Failurc ro sE vorte^ comlEnurion mrcBgc is unlrwiil. rnd sh.ll hFcr !n enDk,rcr n, d6ind Ftuki.\ rnd
<br />ro onc hu ed rhorslnd dollrrs (!lo0,flvJ). in addirion io thc cost o nsalion. damsc\ o\ FDtid.d nr rh.
<br />Slrlion.1076 orlhc l,hn ir cr.{ itrd dtrorrcr's fes.l9rrsz /rE;.?S
<br />ucENsIlrcuNualflB
<br />DrcLdBAllo!
<br />I hcabyilt rndcrpctrrlryolf,rrjrynu I d li.coy{ uddcr povri.tr olchatlq 9 (conrmncins sith Scclinn ro(x)) ofDivi\nJn -l
<br />l?
<br />trs Codc, 0d m, licensc is in tull r'ore ud eflel
<br />"-rr*a.. *
<br />c0Nlilnllcullu^L[N[lNclc[Nll
<br />I hrrcht uflirm undcr F.rhyoltErjuylhd thcrc is n.on{ructirn lcndirEl8cNy li,r rh. r.dormftc ofrhc wort foi *hi.h rhis,x'mil i\
<br />iss,cd(SN .1097. Civ. C )
<br />A}IUIANLDECLABflIAN
<br />I )mh, ifilnnudcr pctrihyolJrrjuryonc oirtu nnb*in8 dcclmrion\,
<br />Dc'fl,lirk,n P..nir\ Ash.{os Norill..hun hdcrul R.CrlrridN (Tirl.40. P.n6)
<br />Rcquncd Irrrft ui Norili..liotr
<br />-l
<br />ccnify rha! rbc fcdcrol rcBuhtions egordinS lst nos Emval tu nor lptlkablc b rhi* pmirl
<br />4l ftni(y rhd I hatc Eod dis appliclrion en siarc rn tu informrt'n is coftcr I !116 $ ondy sirh.llCnyrnd County
<br />odinarcs and srarc kws rchrilg ro building c6
<br />abvc n*nriorcd Dnpcny to. insp.crn,i
<br />Apdkanl or Ag.nl Sig,rotorr
<br />rxrhriz. r.rrcscnrorivcs ofrhh Ciry and Co!.ryk cnrdup.nrrr
<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 />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 />Meter Release
<br />FINAL Ir-21-ltY lrA ?ty,
<br />Notes, Remarks, Etc.
<br />-)
<br />MECHANICAL-INSPECTOR RECORD
<br />Grease Duct
<br />n
<br />r'?2//669
<br />4#ffi:
<br />I
<br />I
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