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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE COMMENTS OWNER BI'ILDER DELCARATION
<br />I lErcby afijrm undcr lEnolry of pcrjury rhd I M cxcr{rr from rb€ Conl@ro^ Licc.$ tiw for lnc folbwing E&$n (S.r.7031.5
<br />alsin.ss and Prolcssion Codc)r Ary Cn, or Coury whi.h r.qoircs ! I*rnrn lo snslro.l, rlls. itrpor. .Lmlkh or (p6h My
<br />ntudue. l.hr ro ts irsum. dF rcquim rhc q,plkd for such Fmil lo filc ! s8tud nalcmfl rhar tr or sh. is liensd I,!N&l
<br />ro rh. pmvkions of rtE Conrocior's Liccnsed Las (Chrprcr 9, Crmmming wilh Scclion 7000 of Ditision 3 olrlE BuliEss a.d
<br />Profcs io n Codc ) o! thai lr or shc is crcnpl lh.rcfro m lnd th€ bsst for I he alkBcn cicqition. Any violarion of S.dion 703 L 5 by a.y
<br />appli.ad for ! lemir subjdts rhc aff'lic!trr ro ! civil tEdhy of flor fl)rc rMn nvc huodrd dolles ($500).
<br />-1.
<br />N oqe. of rh. polEny. or fty .slplotrlr wlh wsScs N lheir sk sry.nsdion. will & dE tqt old 0E {rrm i. ml
<br />inhidcd or otrcEd for $L (Sd.?044. Busirc$ lnd Piof6riont Codc, Tl* Contetot's Lien* &w d@s nor Aply lo m owmr of
<br />rhc prorEr, sho boiEr.r ntpoB dxNn..rn *ho dG sh s hihsclao. h@Uo. thmtr8h his or ncr oM.r9loyccs.
<br />providcd ihal ruch inp,lwnr. rE Nr inr.nd.n o, ofic,ld for €b, lL hoEE lta bu'lding or inpmEr n $B eilhii orc Jer
<br />oforoLrion. llt O{nq BuitL. eill hlE 0E b{dan orprcting dur lE q dr dn nol hrild or iqtut lhc pEFly for iE puID$ of
<br />l. .s .*ncr ol th. Imp.ny. an q.lusivcly conlru.rins *nh liccnscd conrn ros lo otrnrud lh. pmrct (S€c 7Ol4. Busitr\s
<br />!d hDrgsim Codc Thc Conrrlcroas Li.cnsc Law docs nor apply lo !n o*ncr ol pmFrry who builds ot iot.ows rhe@n,
<br />und uhd onrMs ror slch pmlcck wilfi a Co mro(s) liccns.n ,1us@r ro rh. Conracrof 3 Li.n* t w)
<br />UIIBf,EII:COMTTNIAIII}!
<br />DECLAEAIXIN
<br />I hcftby lltim lndcr p€mlly ol pnjury orc ollhc rolb{in8 delaEliors:
<br />I hxrc lxl will rnni'rr(cnili.drcofcon\cnrr.ScltlNncl;rsor(e^.onln.tr\]rn,n.x\t()vnhdi,tllySc.lion.rTlx)olihc
<br />l ntxtr ( {xlc. l,r rhc ncr,onrnfu ol rhc \ork lnr whi(h rhc lf,nnit i\ i\suul.
<br />I hav. and will mtrintin workcrs comFNarion insurBmc. &s rcqutcd by SNl bn !7(n of tnc Lahor C4d€, for lhe Pcrtomftc of
<br />r hc mrk to, vhhh rhis ,cmi is issu.n. My workcr' N'npcnstion insurMcc .Mif urn F$cy .umb.r m:
<br />{ltrnrfyrh.r in rhc rrli,rtu.c. or rh. so,k r.r whhh ihii p.rmir n Gsucn, l shall not.frplo, d.y Pcno. in any motrrcr
<br />Is a\ ro ttsm {hj6r 16 rhc *qt6( 6mp.ns! nn la* ! of Califomis. and ige lh!1 it I sholld tE om suhicl to lh.
<br />qort6'om,'cnsliohpovhionrofSerion37mofihcbborCodc.ldullforlhwith@'nllywhhthosDmvisionr"
<br />WARNIN(i: Failurc to surc workcn'compcnrDlion co(rurc h u.hwful. afrl shall subitt atr emphyct ro oimiml lf,mhas 8nd
<br />ro onc hundrcd lhousnd doll$s (Sl0o.mo). in lddlion ro rht coil ofcohpcnslion, dlnEBg ts Providcd for llE
<br />Scdirr 3l)76 otrlE lrtu (1dc. i c'c\r rnd
<br />*L:*/zag'X
<br />DECIAAAI&N
<br />I hcrcl,y rmrm unncr p. ahyorpcrjury th,I I nnr liccnkn undci provision olChanro 9(co.n ncing wnh Sccthn 7(xl0) otDivi\i6n:1
<br />ol lhe BlsiDcs and tmlc$i(,nrCr ..dd Fy li.cn* k i,r lirll r.nt andclncl.
<br />-7otQ q
<br />IAIiIAIqUQN.LENIIINGATiINCl
<br />I rrrby rmrmundcr Fnrllyofpcrjury lhal rlrcrc n a.on{rucriJn Lndin! atcN, ior thc rerforro.cc ofrhe wor* ror Nhi:h thn Ermil is
<br />hsucd (SL! :109?. Ci!, C )
<br />A.STUCANLD&CI,AMTD!
<br />I lmhy aflinn undcr r.nrlry.rp.rjnryonc oi rhc iollo{ing dLrl0alions
<br />txrmliti Pcnnih.Ashcsros Noriiiclrion Fcdcral Rcgohrbnr (Tirl. 40, P,n6)
<br />-Rcq!tcd
<br />lxllcr oa Norillralion
<br />-l
<br />c.nify Ihor rh. fcderal re!,hlions Eg&ding &rbcdos rcmwl m nol lprlkabh 16 ihh Pmj.{t
<br />-l
<br />ccdiiyrh l hivc rclld lhh ion ukl dnr. rhrr rhc rh)v. irrfornDrnr ncotrccr Irgrcb.o8tlywirhall(ilyonlColnr,
<br />onl nn dsundsrarc tj!\rchrin8 t{,ildins consrtocrion- nnd h.,clty aurhorir rcl,csnl.lilcs ofrhh Cirydd Counry ro cnrs uB)nrtr
<br />abovc mNioncd proFny lor i[
<br />7/"0/ttApdi.anr .r Ae.m s ign. rurc
<br />H-.-zt Lr?it
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />lvlisc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Bough Ductwork
<br />Vents r\
<br />Toilet Room / Clothes Dryer 7 -)o- le x,\L-rr0l
<br />Residential Ranoe
<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 />Rouqh Mech.
<br />Final Test
<br />Meter Release ,6\.
<br />FINAL K-u.-19 !AI-rd\
<br />Notes, Remarks, Etc.
<br />ID/SIG.
<br />-l
<br />m.emp utrds Sdion- B. & P.C for thii aas..
<br />Polhy Nrmbqr Erpics:
<br />-
<br />(oA ._
<br />9a -rn* ?cfct*;t,
<br />t rdeas \,m
<br />-Pmne nrm (pri,n)r-
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