|
MECHANICAL-INSPECTOR BECOHD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BTJTLDEN DEL(IRATION
<br />I ficrchy lmrm lndcr p.n0lry of Fqury rl'ar I d .ichpt fioh rlr Co hcror' Liens Liw for rhc rollowi.g Ersn (Sc.?o:l L5
<br />Blsincss !'d Prurcsion Cod€): A., Chy or Cnunr, which EIIiB a tEfrh ro on\uucl. all6, ioprcw. .Lruliit or Ep.n y
<br />3mcrurc, prbr ro ns is$am. .ho require rhc,rtlta for such prmir io nb 3 3igncd slllcm th.l t or shc ii lienrcd pursul
<br />lo rlE pmvhions of rtr Conhcrols Licco*d L{w (Ctaptcr 9, Conm.mitr8 *irh Scdion 7000 o, Divhion 3 of l,r Buioe$ and
<br />Prcf€*ions Cod.) or rhar lr or slE is excmfl rhcefroo and rhc hasir to, rh. rlbg.d cx.nprion. A.y viol,tion of Salbn 701 I 5 by lny
<br />apDlicant tor a ll€mit sbjcck 0E ,tnlicdr ro a civil lcnalty of nor mre thu nvc nudEd deuars l$J00).
<br />-1.
<br />3s owncr ot Ihc pmrEnr, or n, enDloyccs *ith qascs os thcn et $mp.nerion, will do rhc work rnd tE sln{N n nol
<br />inieddl oroltcrcd ror slc (Se.7044, B$im$ d Pmfc*ions Cod.: TIE conlrd '. Li..n* t2s docs ml +I,ly to N owEr of
<br />llE pmrrn, {,m buildr or nrFm!6 tlEmi. ald {ho dfts sh hd( himsll m hcNclf or lhml8h his or hc, owt c!'rloyss.
<br />,rovacd lhsl such imnrorcnrnh a mt inrcndcd n oficrcd tor $h lil h.wcq. rhc toildin8 or inpmrcmnl h sold sittitr nnc ,vr
<br />ofaftphri,tr tlE Owffi BuilLr qil! hlw ttr b[dcn of FovinS rhll lf, o. snc dn d b{ild m inimrc dE Fo|Er, fd rlr I{rFe of
<br />l. n! owEr or rhc ropcny, am .rclusivcly .onrd(ing wirh li.rn*d contactoF
<br />'o
<br />construcl r lE p.oj.rl (Se ,O44. Busircs
<br />ad Eofc$iotr Codcr Thc Contncrols t.iccisc Lrq docs mr lplly ro otr rwncr nf[opcnywho buildror imnDlcs lhcrcob,
<br />and who .onrek for such Fbjed. *nh i Co.r6do(s) lien*d pur\xd ro
<br />'tE
<br />q,nkrdds LicnE tjw).
<br />I dncx.rrJ, utr .r S..ri()
<br />ullBf,E8S: TMtENSAIqN
<br />DECI,AXAUAN
<br />Ih.rcby fi.fl undcr p.Mhy of pejury om of lh. following d.cl,ralions
<br />-l
<br />hrvc rxl willnuinrrinr Ccn ilEure oi Conrcnr to SclI-lnsue tu *orkcr' comrcn{orion- !s polidcd t, hysccrion 3700 ofrhc
<br />tjb.r Codc.lnr lhc rErfomNc olrhc work ld qhich rh. Fhnil is n$cd.
<br />_l hovc and wi'l n.inrain *o*cr' con cnsdion inslEncc. ss rcquncd br Salion :1700 of rhc Lib6r C.dc, ror $c tcrlormncc of
<br />thc *ork lor *tich rht Frmit is irn&!. My worlqs .omrEnsrnr insururc .ei.r ard Flicy ntrnb.r m:
<br />Policy Numb.r:Jrpet
<br />_l ccniryrhar in rhc llcrr.mn.. otrh. *6rk 16r shi.h rhn l.rn h issucd. l rholl mt cmploy .ny pcN,. in a.y muncr
<br />s s lo b€onE subrc.t lo llrc sltel com!,cnsal ion hws of Califoni!. and lsN lh,r if I slsuld bccoe sbjc.r ro lh
<br />wo crl c.mp.nsotio. pmrisiofls of Setion 3700 of lh. Labor Codc. I shall. fodhwith omply wirh rhos pmvi.ions.
<br />WARNIN(; Failtrrc t, Krrc $ltrkfi omptnsdn n corcntc i\ unlrwlul. d !h.ll subjccr an cnuloycr k, Lrinind pcmhic\ lnd
<br />(i!il lnrc\ oF b onc hundtu rhdxsnhd dolld^ lsl(x),(XD), in iddln,n *ru:*",,\r.vidcdf.,hc
<br />2
<br />uctirtll).roNrxacra&l}[cljtAuoN
<br />I hcEby rliii,n undcr pcnalryol!.tury lhll I0m liensn undcr t,ovisioo ofCnlplcr I (connDnch8 enh s{tio.7uJ0 oaDivhion.l
<br />of rh. Au\irc$ r d Pr.fcsk,.\ CoJc. ml my li.cn{ ir in tu ll (trN anl cftar
<br />AITLEANLDESAA6ION
<br />I rgtbyrmmundcr Fo,xy ol!.rruryonc oarhc lollo*in8dccl nrions:
<br />D.'nolition P..mit*AstEnos Noiificuti('n fcderrlRc8uhtions(litlc 40. Pan6)
<br />_Rcqrtcd tr(s of Norifi.,lion
<br />_l .ctiry ihd $e lcdc.a, rBul,tioB EeaftlinS !s6csto! rcmval G flor apflk3bb lo rhis Dojer
<br />-l
<br />.olify tlur I hrw rcad fth ap0lk{io. ard {!r. $al tt ahivc info@tion i! .o,mt. I age b .o nl,'lysirhrllcirydndcounrt
<br />Cily and Couly ro enrcr upon r,E
<br />^, 7y'ry' r
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rouqh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Range
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Grease Ducl
<br />Fire Damper
<br />Openings
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.I t4ltx -fiJ(ry
<br />Final Test
<br />Meter Release /aa
<br />FINAL I Ylt*Tue*,cvl 7
<br />Notes, Remarks, Etc.lt
<br />Duct Work
<br />Other
<br /><{-
<br />CONSIBIICIONIENIINq.ACENCI
<br />I h.ehyafit ud( FnnlryofFrjury rhd {hcr. k s c.nsrtu.rion LndinS +ck_y lor lhc perlotrrumc ollhc {ork tor uhi.h rlrh pcanir is
<br />hsucd (Ss 1097. Cir. C.).
<br />trndn\ N,'nr
<br />-
<br />tt
<br />IT
|