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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE COMMENTS O\IN IjR I] LIILDER DI]I-C RA'I'ION
<br />I hcruhy ullnr udcr prtrrlry or Nrjry rld I rD cxcnrfl hnn rhc ()nk rF l.iccnsc l,aw t, rhc lalb*ins rcr$i lsN70.rl5
<br />Ilun r\r r d l)'ofusi{r C(xlcr: An! Cir} or Counry Nhich rcqrnc! J pcrmir r, con{rucr. altcr. inrpiovc, dcm'li$ or rpxtr rtry
<br />{ni.ttc. |rorf ir\ i({r(t.c, rl$ rcqunc\ rhc rml'.r lir srrh Fnnn t,lilc n.i8tcd nrrcm lhnrhc.r shc h liccn\cd Durnrllt
<br />npplic!0rlnrrrnnirubjccr!rhcupplicanrrorcivilI.Nlry.ltror,rtrclhrtriivehundrcddoll0F(15(xr)
<br />-!191. N o*M olrhc lloFny. or my cn!,loyEr sirh w,Ecs s rhe ir slc comp.nsrrion. vjll rlo r1r eMt rrd rlE rr,]fu b mt
<br />-inrml(n or olicEd for qk (58.70{4. Busirc$ rnd Prurcsions Crnc Th. Conldcrois Liccns L{* {,o.s nor sprly ra an ownE oa
<br />lh. P,op.n, who ttrids or inlmB th.Mn. I'd who dG sh ft* himclr or hNlr or rhrou8ll his or h.r om cq,lorccs.
<br />providcd rh{ sr.h inprnrEnB N er h'cnLrto,oflcE{ for stc li h.}*i dE toiui.g or iqr@mnr is $ld wirhin om rw
<br />ofcoq,lcrbn, iE O*rcr A! !r will hlw rlE hod.n ofpmving tlEr lE m sbc dil tur buiLl or iqmrc thc prDIEIy for rlr puqb* of
<br />-1.
<br />!s ovmr of lhc lopcny. !m .rclusivcly .on'mclinS wilh li.cnEd .o.t.ocloB lo onsrud lhe pmF{l (S€c. ?044. BuriNs!
<br />ond ftrksri,n Cod.: ThcCo.lla.ror's Li.co* Liw dds Nr llplr ro an owncr ortmp.ny eho builds or intmws rhcron,
<br />rnd who conlmcls for such poFts wirh. C,nrmdons) liftned lrsunl roihc Conrracltr s Liccnsc Lis).
<br />I an.rcmnr ua,l.r Sftti]n
<br />D ",' ) /q - / <,'/t-T- 1 7
<br />DEII.AEAIION
<br />I hcrcby !nn'n lndcr I'.Nhy of pdjory om of rhc tbllo*ing dc.Lruriotu:
<br />-l
<br />hsE dd will minr.in a C.flifEatc ofcoBnr ro SdfiNuE aor work6 mqEnsarion. !e Fsvid.d for by Srcibn l70O ot rlE
<br />tnhor Codc. for ttr p.rf@,E. of rh. {ort for whi.h rlE Fron ir isru.d.
<br />_l hlve lnd qillmoinloin porkcr'conv{nslrion insuhnc.. !s rcquncn by Serhtr 1700 of lhc Gbor Cods. for lhc !.rfortuna ol
<br />rhc *o,t lor whth thh pemi n tnE<l. My *ortcn comiEnel ion iffummc carier and polic, nunbcr d:
<br />-)-y *niry rhlr in thc pdro,romcotrrE work ror whf,h rhis Frmir i! tsucd.l shall nor cmploylny p.rsd in any Mn.r
<br />vi Nrotc& {birr ro rhc aorkr{ emncntd ion h*! of Californir. and d*@ Odl il I should b.coft .ubjcd lo lfu
<br />ertcB' oqrn,llion povirb.s of Srrion 17{10 of rhc kbo. Codc. I sh.ll. ft)nhwirh .omrly wirh rho* pDvirions.,
<br />WARNINGT FiiluE ro su.. worteB ompunsdion coverag. is unlawlul and shnll subj.cl .n cmploys lo riflinol Fmltics und
<br />civil fircs up
<br />'o
<br />otrc hu.drcd rhous0nd dollm ($100.000), io trddnion ro thc cos of conpcnelion. &mgcs !s !ro!idc{ n, $e
<br />Scctiotr 3076 ofr&, tlbr Lrodc, irrlcrcsl {trd allfftrcr's Lc$.
<br />ttt, . > 19 ltr
<br />u![utfDi9]traAcraa
<br />UECLISAIIO!
<br />I hcrcbyliltDu cr ll.nohyoanrriury lhllI ur liccncd undq novnFnolChuprcr I (commkins *irh Sc.rion 7(x[) orDirh'on ]
<br />ol' rhc Busnrs nnd P.ofrsions Codc, o.d my liccns is m rull rbrc ard cncct.
<br />Liccnsc Ckssr-Liccns. Numhcr:
<br />lr.t.: Corr*loi
<br />!!2!iISICIAUJNDILIi-A!II!!
<br />APPLIC NT DI]CLARA'II(}N
<br />I taEh, u0innundcr l{.rliy or p.rju.y om olrhc nnL,$n'8 dcclflrions:
<br />D.trbliri PcnnirrA$.(u! N rili.rrtun fad.ril Rr8ul,ri(,n\ tlirl..10, Pan6)
<br />-Rcquncd
<br />Lcncr of Norii!_nrn)n
<br />-l
<br />.cnify rhar lhc lcdcBl rcslhrn,ns Eslrditrs .stEslos rcmval urc mr lpplicablc ro rhi pDjar
<br />L\il enily rh t hlvc rcad rhis up, tar btr uxl sllr€ rhar rhc anorc iflformr ion is coEr. | lse ro @mply enh aU Cn, ad Coury
<br />odimtres.nd Slalc La*s Eldinr ro huildin8 conslrucl ion. .nd h.rcby au'ttorn EpE$nlalircs of lhis Cily a.d Colnr, ro .ord uFn dE
<br />lbot nEnriorcd pmtcny for
<br />Applic0l or Assnl Si8rulurc:
<br />Permirs iom (r,i ) -L ry - l-ry-/?l^ snl.(o1,,o., . ,
<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 Deteclors lnstalled
<br />Rough Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<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.7'D)
<br />Final Test UI\
<br />Meter Release
<br />FINAL i \11t4 fr .a)
<br />Notes, Remarks, Etc Jr
<br />-l
<br />ID/SIG.
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