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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE COMMENTS
<br />Appliances
<br />lr/letal 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 D rYer
<br />Residential Range
<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 />Rough Mech.8/d /rc 5t>€t
<br />Final Test
<br />FINAL c*,/l{/rt '.-^56
<br />Notes, Remarks, Etc
<br />OWNER BUILDER DELCARATION
<br />I hcrcby antrn urler p.nalty or lcriury ftat I m excmpr foh $. Co r&!06 Li(q* Lie f6r lhe folloei.r usn (1N.79J1.5
<br />BBin€rs and Profession Codc): Any Ciry o. Counry anich rqui$ r |tmh ro @nmud, rltm, in!l!6rc, .kmlhn nr rcprn dry
<br />sttulm. rior ro ars hruucc, oko reqdrcs rhc a9llic&l f.r such Fmir ro lik 3 si8n.d slalc@nr lh lE or sh. is lie .n purtultt
<br />h rnc Fovisio.s ol tlE Conxstoas Liccnsd Llw (Chaptcr 9. Comrcing *i$ Secrion ?000 ot Diviiion 3 olrh. ABi.car and
<br />Pmf.ssions Codc) or rhat lE or sh. i!.xeru rherclioft ud rh. basis tor thc allee€d eren{niod. Ary tioLrion ofs.clion ?0J I J by uy
<br />arylicant for ! lEmir biFr3 rlE q'pli.s| to a .ivil p.tuhy of rcr mE rh,. fiE tunrlnd dolrs (S500).
<br />-1,
<br />as oqicr of thc F!,Eny, or ny rmploy*s wirh *agcs $ rncir slc comp.neri.n, wiu do th. qrt !r'd tlE strutm b mr
<br />inlcd.d or ofi.md for 3rL (5(.7014, Busirc$ and Profcs.ion. Codc Thc Conlr.clM s Lk.ns l,s do.s mt opply lo !n ower of
<br />thc pEFny wlF trilds tr iqmB $cmn. ad eho dms *h 6rt himsclf or h*slf or rhDleh hh o, hc, own eoployecs,
<br />prcvidcd lhar suh inprcwmnBmmri cBLd troltu aorsL.la. hoeE, tu hildi.e or iqmwEnr L sld wihin om r@
<br />of oq dbn. 0E Ow!.r Buildcr *ill Mw 0r hqlcn of lmving tur h. or sh. did mr bdld or in n'k dE lretdy ld tlx ptrFft 6r
<br />L Noqnfi.lrhc pmpcny. anrrclusivcly.onrding wnh lic.nscd conrmcroN lo construcl llE pmjcd (S(. 7044. Busrcs
<br />ad E!,cshn Codc: Tnc Conlrocrols Lkcnse tjw do.s nol oFllylo an osner .f lrol,cny {ho buildsor idrmvc\ lhcrco..
<br />a.d who cod$.( for such pmjccrg wnh . Conlr.crons) [c.rsd puhuMr r. rhc C.nh.bls Lk.ne tjwJ
<br />I m cr.npl undcr Sk'.l io a & PC. lnrthhrco$n.
<br />IABf,EIN:IITMfINSAIITTN
<br />DECI,If,A]JA!
<br />I n rcby amrm und.r p.Mxy ol pgjury om ofllE followin8 del,rarions:
<br />-l
<br />h8B o'd siU @iii.h r C.aifr.re of Co.Enr ro Scllhs@ for works omp.nsrion. !, pmvid.d for by S*tion l7m of rh.
<br />t$or Cclc, to, rhc pc.f@ of th. mrt( foBhhh rlE F6nI i! hslcd
<br />-l hovc rrd will roi.rrin worlcs comFm.rion insur0mc. .s rcquiEd by SNlion 3700 of lhc Ldioi Cod€. for !n. ped{,Mc. .t
<br />lhc wor* for which lhi\ p.rmn i3 hsn. M, wmt R' omp.nsdion insumc .micr od rFli:, nlnbd e:
<br />*dk FL,tu^
<br />1368
<br />-l
<br />ccnify rhor inrhs pr,fortu..e of rhc *ork for ankh rhis tion is itsued.l shlllnol crploy uy pcr$n i.anyDUrcr
<br />s !s lo bcconr subictl b lh! vorkcro'mmpensark n [ws ol Cllifornin. a.d r8r that ia l shuld bcom subr€{l ro ',rworkcs' orlpcnsl ion povisions ol Scclion l?0o of rfic lltor Codc, , slEU. fonh*nh conply snh lhoc povicbn..
<br />WARNINGT [dlurc 'o
<br />suE wort.rs compcn$lio. .ov.n8. is utrl,*ful. lnd rhill subjRl & eq,loyc,lo dintiid pctullics dd
<br />civil n6cs u,' t'.n. hnndrcd thousrnd dollus (slm.Un). in lddilnrh ro lhc cosl ofcomFnsrlion. doroEcs as lrovidcd f.r rhc
<br />Sccri(in 1076ofrlr.t;,htr(-(xlr,ir cto{r du onry'\ fcr\
<br />LO M
<br />IISEISIILCONIBACIAA
<br />IECLTIAIIO!
<br />I hcrby umnn und.i pcnrlryolpdrjury rh,r Ln liccn$d und$ tmvniotr olChrntcr 9 (commncin8 rirh Ssrbn 70(x)) orDivhion l
<br />ol rls Bu\inc$ and Pmfc\snnis C(}dc.,Jd mylicctr* i\ in tull irxN drd cflacr
<br />ts lolTss 6
<br />caNflAIJelIatrL,ENrllCrlGliNlJ
<br />i\\u.J rSN :lot)? ( iv ( r
<br />AITII{:AUII}ECI.ABAIION
<br />I hmtly oflim nnd$ l.nrlryolpcrjury onc oflhc foilowing d(le0rio.s
<br />D.rmliion Pcrnrirl sh.(os Notilicirion ltdcr(l RcSul.rions ('lirlc4l). Pin6)
<br />-Rcquircd
<br />Lcrrcr oi Norifrarion
<br />-lccnilyrh
<br />rncfedcrallcsuhrions resrdine asb.st,\ rcnrlll m nor rpplic,hlc ro rhi\ nmFcr
<br />ZiJ ccniry rh( I tutrc rcd rhh applicarion !d \l!rc rhir rhc ik,vc inli,ruri('n i\ c.r.cr. I rtie to mnDl, {irh lllciryafrl Coutrly
<br />onlinrkt.0nd Srar. Lrws nlttrin8 lo bxildirS c.nsrurri(,.. d{ h,cby ourh.rn. rcrcsntlrnc\ nrrhi\ Ciry aid Counryt' cnrn u|rn rhc
<br />trhow
<br />'nnrion.d lmp.ny ror instBrion
<br />d
<br />Z+Vr Arl6t //o
<br />I
<br />ID/SIG.
<br />Meter Release
<br /></2A /lli
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