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MECHANICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDE& DI]LCARATION
<br />I h.rcby amrn undcr !.ndry of pc+ry lhll I m .Empl fom lhc Cofltr4loE Lienp Law for lhc folloqinB r€&$n (56.7011.5
<br />Blsinc$ ad Prorcssioi Code); Any Ciry or Coonry qhich Equim a IEnir lo @osr cr. !l!d. iriNrrcve. &mli.h or Epat ey
<br />slruclu.. p.br lo nr issuarcc. alqo Equn€s th. apJ,lic&r fo, .kh lrmii ro Uk r sigmd sl.lcft lhd & o. sn b fie.scd puNanl
<br />lo lhc JmvLio6 or rh. Coolr.cror's Liccn$d L,w {Chrlier 9, C6hmncing wnh Se.iior 7(100 of Divkio. 3 oallE Busims md
<br />Pmfc$hnsCod.)orthllnorsheiscr.ntllh.rcarom&dlh.basislorlhcallcscd.rcnption.Anyviotrlionofs€diDn?0llJhyEny
<br />ao,lica lor r pcmir $bj(ls rh. rmli.ant lo r civil penalry o, not mc rlM fivc hudrcd dolles (1500),
<br />-1.
<br />N own.r of thc pEpcny. or my cnploy.cs wnh w.g.s r tlEt $le @mFnetion. will do llE wori .d tlf drxre k mt
<br />inrcndcd d ofi.rcd lor slc (Se.?O14, B8ituss and Pr.f6sio.s Code Ttc Cotuetoas Lhcn* kq do.s nor !ppl, ro &. owNr of
<br />lhc pmFny wh6 hilds n i'qio6 rl*@n. and sno der s.h ed( himlclf or hcNlfor lhbugh hh q tE, own crlploycB.
<br />pDridcd rhll such impmvlm' s m ml inlcnd.d r otu Lr sh. li hoscG. rh. t ilding or i,pftmnl is sold vilhin on. )ce
<br />olonplclbll. tlE OwM Buind wil h8E trE hrnL. orprsvinS 0ul tF or dE did br boid or inq,ow tE pEr*tiy t lh. pEFc of
<br />I, asowo.r.trhc poFny. amcrclusivcrycontocrirs {irh lien{d..nlrsroN ro oi{rud rh. FDj(r (SN 7044, abirc$
<br />ond PBfsshn Codc: Thc Cofllrlclols Li.cns. Law docs nor aptly ro rn own r .l propcny who builds .r impmrcs lh.rsn.
<br />aod who conlnctr for such Fojccrs wirh r Co rcto(, lienscd nuruunr ro th. Conl.rrols Lkcns Lr*).
<br />---l u .&Epl ur'.Lr S.dior-. a. & P.c for lhi! Ee!
<br />OFE :_- _ ,._
<br />!0tf,E&sir0MtENtA:IIIN
<br />DEI;LAIAIII}!
<br />6oYd,';2-t.y'1/,f
<br />-l
<br />ccnity lhd in rhc p€rfor@c of $c wort for which lnis p.mil is issmd.l sh.!l not cmtloy any pcrson ir.n, manE
<br />$ ar ro b.oft subist ro rhc s.tc6 omp€trstiotr lavs oac&lifomi4 lnd apEc thar if I should t*comc slbirl ro rhc
<br />volksi sqrnstion previsions of Sc.lion 3?00 ol lt tihor Codc, , dEll. fonhwith comlly wiln lhos prcvisions.
<br />WARNIN(;: Failurc ro scurc workc^ conpcnsrion c.vcnsc is unla$nrl. lnd shlll luticcr dn cnploy.. ro oinin,l lf,n lris md
<br />cilil nnes !p ro orc hundrcd rtolsnd dollar (Sl0O.0OOl. irl 0ddirion ro thc cosr ol coqrnsrrion. d!tuscs ns p.oridcd td ih.
<br />Scclion J0?6 of rhc titry Codc, inlcrcsl und alromy s accs.altls
<br />DECIIAAIION
<br />I hcnhy nflirrumlcr lcnrlryofp.rjur! rhd, nn li.cn*d u'ilcr l,nrvi\i,,i ol Chdfr.r 9l..ntrNn( g wirh Sccriotr 7Ur0)ofDivi\nn 3
<br />oi ih.0u\incs\and PrnasioN Codc. nl my licco\c n ir tullri,rc-udcftct
<br />E ./oa {d7
<br />Ddq-L clcls *-,t G)zo+?ta-S
<br />COIj'IB.UEIIQNII]IDIICrII !(I
<br />I hcruhy rfln'n undcr rniiyofFrlury rtui ltcrc i\ r cotr(ruclion lcnding.Eciry t{r rhc nrinnlncc orihc trort r.r $hi.h rhn frinir i\
<br />issu.d rscc 1097. Civ C ).
<br />A.tfl.lc ttll)Ectl&&ro!
<br />Ilrr$yrfin trdd$ Fnrlr, olprrjrt otrd ol rhd f{ilbwin8 dLrLrrli{nx
<br />Dcnnlitiotr Pcrnnrr^shc(osNotili.dion Ircdchl Rcguhion\(lirlc.l1). !in6)
<br />-R.qui'cd
<br />kllcr ot Nolilrrrt,n
<br />#ffi;ffi-;d;
<br />cgadn,E lshcdos rcnr)ral lrc norlpplicrblc h rhis pnjccr
<br />ndd s|dc
<br />'h0'
<br />d.6ovc idfo.Mrion ii corccl I lglc toomplysilhlll Ciryand Counr,
<br />aurhrir. rcprcscnrarivc\ oarhi\ Ciry dtul counryb rnr$ uFr rh.
<br />{ft)vc rciri,rul fn,nrnr ln i'}prcri{tr,
<br />Applicet or AB. Signau
<br />Prftr'e n@ (Fn!D:;(l
<br />^*,
<br />i a/.s/4
<br /><86--a,/\./6
<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
<br />Rouoh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Ranqe
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Fire Damper
<br />Openings
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Hough Mech.b/t{//v 5\ sb
<br />Final Test
<br />Meter Release
<br />FINAL KlA/ &c?\\dd
<br />N otes, Remarks, Etc.
<br />--t\
<br />Grease Duct
<br />lnstallation
<br />I hcrcby urfih undcr pcnrlry of pcrjury orc ofrhc ,I,11,!ins dalomrions:
<br />-l
<br />hrre Bnd Nillmainrain uCcnificdcolConscnr k, Sclalnsurc for sortc^ $mpcnsarion.as pNvidcd lo, hySftrion 3700 ofrlr
<br />tlto. Codc- tbrltc pcnhrmrcc oflhe wort for *hich lhc pcm h ksucd.
<br />lhav..ndwiutuinlainvo.kcrs..dp..sarioninsudkc.s equircdbysc.rionlT(x)orrhtblxrC.dc,lorrhclc.iorronccof
<br />rhc mr* fDr shi.h rhia rd.rn ir isocd Myeorkc$ enpcnetion insuru.E .sicr uJxl l.licy nun$cr re:
<br />c*x, . F,,'t,1.,c, aL ?ai, F ic- /,5 . a-<)
<br />a2
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