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APPROVALS DATE IDiSIG.COMMENTS OWNER BUILDET DELCARATION
<br />I ficrcby omrm under !.nrlry of Frjury rhsr I m cxcmpt 6.rn rhc C..tmcroF Liccnsc Llw for rhc lollowinS rcason (Se.703 1.5
<br />Blrincrs .nd Prolcssion Codclr Any Ciry o, Co!fly *hich Eqlircs ! Il€dir to connod, dr€. i8{,rov.. .r.mlish.r rcpln dy
<br />nrudurc. p.iorio ns issu a, !l$ Equnes lhc applicd for such pcrn lontrsi8rcdr cftnl thal h.orshc n licci&{ pu^udn!
<br />lo rh. pmvision! oflh. Conlrelols Liccn$d Law (Chnllf 9, Cor@Ei.8 wilh S.clion ?0o0 of Divkion 3 oflhc Busiflcss and
<br />Pmtcssiotrs Codc) or rtlr lr or shc h crcmrr thcrcfmm lnd rh. tEsis aor lfic olhgcn crcq,tioi. An, violrrhnofS*rion 70.1!.t by rry
<br />amlicrnr Lr ap.rmn slbhcrs thc sppli.aor lo ucirilpcnalryotnot mrc$d nec hundrcd doUes {t5oo),
<br />-1,
<br />ss ownd of lhc pmFny. or my cnrplol@s wil! str8.s .r rhcn ph .oq,cn$liotr, wiu do thc wort {d llE stnt1m i.s ml
<br />intcnd.t or oltercd for sh (56.7044, Bosiftss ud Prcfdsions Codc Tlrc Conriacroli Ltcne L,e rlo.r nor rpply ro d osmr ol
<br />lhc pmn ny who hoilds s ttsmEs tlEEr ltd who dcs sh hi( hinsclf or h.rEtaor th&lgh nis o, nct owo cnployes.
<br />pmvid.d lhar such impmEflnr, fl mt inl.,*d orofr@n tur sL. It ho*cw.lh. boildin8 or ir{,rokmnI is sld *ilhin onc J&r
<br />ot onplcrioii. rlr Oeftr Buildd will hlE ttE buld.n 6f Foviry tur l* or r,E di, er t ild d int&w tlE FnlEly for dE p{rFsof
<br />L arown$or$c In,p.nr. ,n.xcluiiv.ly.onrding wnh len{d cont&k,N ro conslrud rh. ,,sircr (SN. ?044. Bu$rcs
<br />and Eotusk n Codc: Thc Co,rr.crols Li.cnsc ljv dNs nor aptlylo !n own$ otpn,pcny who buildsor inprov.s dcrcon.
<br />a.d who o Mls toi ru.h p,oj.crj with { Contfth(r) licsed Dui@ ro rhc Cunio.lo s Lt n* t!w).
<br />-l
<br />m e x.npt $d6 Serion- B, & P.C. for rhh M$n.
<br />l)nr.
<br />xllBtrs8s:.qQMPasa]x(a
<br />DECI.Af,A.UO!
<br />I hcEby olfirm ude4cndly ol pcrJury orc oafi. folhwin8 ded.rions:
<br />Lrh{ Cod..lir rlr |t fonnnN. ol rhc s,trli i, qhich rlrc Jr.rir r i\ r{r.d
<br />_l hcvcandwill m.inrain qorkcB' conFnslrion insu,ukc. !r rquircd by Sdion:1700 olrh.l$o, C.d..lor th. pcrfollrmc of
<br />thc strt for *hi.h ltis pemil is h-rd My work6 ompctrstion insuBmc qricr &rl poli.y nunlE dci
<br />ft6f rNsUPftMr sgP^tCE tNL
<br />t1l?4 I rrir yF,zr v-o-] I I o *\<1 21 o
<br />I edi! rhd in rhc l).rronnuno ofrhc wort n" which rhis pcrnrn is hsuctl, I shrll not cmploy l T
<br />$ !s ro b(om subjcct ro thc {ori6 ompcnsltion h*s ol Cllifomi!. md lBrcc rhar if I rtuuld tr!o@ $bid ro tlr
<br />worksl onrFnsrlion provisions of Scclion 1700 of lhc titor tue, I shau. fonhoirh ontly enh lhle phvisions..
<br />IVARNINC: Failurc ro <rrc qorkEF conlltnsdion covcrasc is ula{ful, Md shrll subrd M cnplo}rr ro ainri.al FtulrGs and
<br />civil fiGr up 10 oc hudrcd !
<br />xx_-Ftrg
<br />h.ueld dous (tl0o.00o).
<br />inGEn .d anomy'i fc.
<br />-
<br />ADDIot-
<br />I Mnhytrnnflrundcr pcmlryolpcrrurylhrr I n liccnslundcrprcrisiotrolChrllcr9(.onnncicin!wirhsc.riotrTlx lolDivisn l
<br />ol rh. Bueic\,trd PioLssnnN Codc, xl nry li.ctrsc ir intullf(rer clltcr
<br />lq
<br />Irr lr <
<br />I hcrchy ofim trndcr ncnlllyolpcriuryrhr! lhcrc il r connrucl
<br />i\\ucd (Sr..1097. ( iv C.l.
<br />kndins lscncy r.r rhc p.nanrurcc orrh work ntr whth lhh rnnil is
<br />AIIUIANLD!iEL^3ATj]N
<br />I bNbydlnrr trnlcr pcnrlrr oiJxrjury orc or rhc lalbqirrr d(lxrrri,!r\
<br />I)on()lirnD I'crrnir\ A\h.no\ Nor'llcaii(n l-cd.r l Rc!ularirnx fl itlc +0, Pnn6)
<br />Rcquncd b(cr.l Norll.rlof
<br />-l
<br />ccnify rh,l $. fcd.El rc8lblhns E8aditrg ssbcslos rcmva! rc rel otrlicatlc ro rht poj.<r
<br />l.cniry 'hd
<br />I t$vc Ead rhlr ap0lidtio.,.d alc I corer.l !8rc roomtly*ithall Carya.d Counr,
<br />ordinanc.s uDd Slale bws rcldinsro pE$.l.riws oarhis Cny lrd Counryro cnrerllnn rnc
<br />/,"::,,:"j:4
<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 I 2<\
<br />Rough Ductwork Vao-rtZz t-'-a",il&:v
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Range
<br />Other /uJ-.'1,2D./8 Z C.-*,??_)
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />Openinos
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.
<br />Final Test
<br />Meter Release I
<br />FINAL ),za46z O<ue,E ;-/
<br />Notes, Remarks, Etc.
<br />c
<br />MECHANICAL.INSPECTOR RECORD
<br />_ C@tmior_
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<br />ttlt<- T-'
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