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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OI!N I]R BUII-T}Ei DTJI,CARATIoN
<br />I hcrchy rfitm unlcr nLnalrvol nrrjury rhr I m cxcnfl li1rn rhc (ir rrdo Loisc lrs fU rhc tull.$in8 rcl$ (SN70.115
<br />llusircs\ rnl Prurcsn,n cod.): Any Ciry or Coutrly Nhich rcquncs I Frnril n, ..n{rucr. rllcr. nn[ovc. dcnmhh or rcnrir rtrt
<br />{ocnrc. pri(trlo ir\ r$ua,rc. il$ rcqurc\ rh. lp/i,nr ror\u.hr.nni' t{, filc I \igncn $arcmnt rhrr hcor {h. n liccn\cd lunusnr
<br />to rhc pmvi\nr\ of rltr Coirrrch\ l.iccn{d Las (Chrlcr 9, Comnrn.ir! riri Sccrion 70fl} ol Di !n,n Iolrhc Busincs\ rtui
<br />Pr.fcssiotrsCodc) oi'hrr h.or\hc iscxc rpr rhrrurrooand rhc hasi\ ti)rrhc allqcd crcmrlior AtryviohrnnrolScdionT0ll5htan,
<br />lppliunlii{a p.nnir suhjc.rslhc rtl1ic,trr Io aci!iltcnalryornornxrcrhrtr firc hrndrcddolla^ (5500)
<br />$.u, u*,"."r,,,.p",*ny,,tr r,.mplor.c!trirh*nsc(u(ihcnencc.nrFnsdNn.srllddrh.workudrh. ocrurci1troi
<br />i'nc'xlcd orolitr.dlorsrlc(S.r7(}l.l.Busircsmdti,fcsn,n\Codc'lhcA,nhdoi\l-icnscl!$docsnoraDplyronnowocrof r
<br />rh. $iFny alx) huikl\ o. i'Nxtu\ rlf,[-D. nl t,n, dms {Rh q!,i( hinrrlfur hcr{ll.r rhn,u8h his or hcr o*n c'ntloy.c\,
<br />nrcvnkd rhrr \uch inllno{nEnN rc mr iflckldl or or rcdrl kr {'!c lr" hos.\cr.rh! huil(li'rg or inpmrcn.nr is knd wirhrom y.n
<br />.l.1x,rrLrin rh. O*ncr Buikt r *illhavc rhc honlcn ofrn,ling (tur ht or \h. did nor htriki or i'nproE rhe poFiy hr rhc puqx'e oi
<br />L as.w.cr otrhe lopcny, ad ciclusirly controcrin8 wnh liccn*d .o.r!dou ro sindd rh. !rcj*r (se,7u4, EBhc$
<br />!r'd Proftssion Codcr Thc Conlmtors Li.cns. tjw des et {Dlr ro oi o*rcr of ropcrly vlD builds or imprcrs lherso.and who @nhcrs for suct ImieB wnh . Conhcro(s) lisn*d plrsunr lo rh. Conrkrois Lien* bw).
<br />-l
<br />m cx.mP unda Sftrio._, B- &,q.C. for rnis
<br />DA;I,IBAIION
<br />I hmby ,liirm und.r pcnalry of prjury orc of rhc louowin8 delarsln,nr:
<br />I nrk ald will tuintain , Ccnirrrlc of Con*nr lo Sclf-lnsue ror sor*.u 6mp.ns0rion, xs pmviled fo, by Serion l?0o of
<br />'h.tihor C!dc. for lh. pcrforlnlre ofth. mrl for *'tich rhc lcmir h issxcd.
<br />_l holr and eill m.nnlin workc* .oop..s.ridn i.slrancc. as rcquircd bySstio.l7{X, otrhc Lobor Codc. tor thc perfommc of
<br />thc lorl tu which thn p.mir is issucd. My eork i* conpcn$rn,tr i..uramc cutr ad policy truhber e:
<br />'Ll
<br />c.diry lh,! in t,rc Frfornm of rhc uorl lor uhth lhis F,oir is isscd.l sh{ll mr cmploy.ny FMn i! my nuMs s lo bc<om subiu io ihc m.lloC con c.$lion lsws of Califotuia. and a8E rhll if I sholld b.rom .ubid Io rlr
<br />wort6 .onFBarioo povisionrofs{rbn lTmofrnc kbor Code.l dEll. forrhwirh snply w n rhos provisions..
<br />UCtrNSELCONISAI:IO.B
<br />DECLAB{IIAN
<br />I hrtuhy allttr utd.r ttrrhyofltr]try rlrr I .nr li(nai ln,lcr tm!i\n,n ofChJ|r.r 9 rcoNmn.ing virh S(rion 7UX, oIDir,\i,,n.l
<br />ol lh. Bu\ircslnkl Pn'L!{on\Codc. I rt li.rnr is in tu||lnrc. rlclllcr
<br />licens Cless:_Lkcns Numb.r
<br />CANiIBIiCIIONIADINGICENCT
<br />I lE6by afftrm !nd.r FMlly of pedury thd tlaE b . oElocrioi la{iig .!fty for llE p.rfql1@c of 0c wtrt for whih ttis Frnil ir
<br />tsued (S(. 109'7. Civ. C.).
<br />/t-J cqrify tlul dE tu nlEgrrLrioB Errdirg.ib.!roi Emvrl e nor applizbL ro fii prei*r
<br />A:l sniry th{r I hlr Erd rhis ,mli.lrion {d sl6re Oar rhc rtDlc inromrion is sm.r, t sgB ro coq)I, wirh s cny lnl counry
<br />.idn',mcMnd Srtrrc bws rcbri4 r{,1,!ildins conslrucriotr. and hcr.6yaurhorizc rcprcscrr0tivcs offin Cit, dCou.lyloenlsurontE
<br />,bove mnri.Ed IjDFny fd '""w'z-
<br />Appli.lnr or Agcfl SiSMl
<br />Sfer. ^ 'G/ 2t )t(,
<br />Appliances
<br />Iti'letal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Ivlisc" Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rough Ductwork
<br />Vents
<br />To ilet Room / Clothes Dryer
<br />Residential Ranoe
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />lQpenings
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rou gh Mech.6 ?1 8y )K Pq ),bC4,.4
<br />Final Test a
<br />Meter Release lt
<br />FINAL lt$\(tl ,,L(/l/4 'A)
<br />Notes, Remarks, Etc
<br />Compressor
<br />o"", G/zr ltg
<br />WARNINC: Fsilue k, surc workcc @mpcnsolion covcmg. k unhwnil. and shall subj.ct grtlloy.r to aiminal lrMhis ond
<br />civil fitr.s uti ro orc h!.d,cd rhouslnd dollu\ (Sloo.om). in addibn to rhc cosi ofcoq,ctrs.rion. domBcs os rrovidcd lor rhc
<br />:::iH,?lt'ixJ"S<p-.^. .^
<br />t !cr! Nm
<br />-
<br />Lnd.r's Add.css: _
<br />r pprrr:iiiliiiiiiiiidF
<br />I hoE{ry.fiim under pcn0hyofperruryonc oflhc followitrg dNld.rions:
<br />D.tulirino Pcrmir AstEsros Norifi.rtion ljcdcnl RcSulat ions (Tirh /r0. P,n6)
<br />Rcqun d 1.tr6 of Notifrriaon
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