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APPROVALS DATE ID/SIG.COMMENTS ol!Nillr Btrll-DllR Iral.cARATloN
<br />! hcrchy rllnnr undcr t^-nrlry ()r l.rjrt rhJr I rnrcrcnrPt iron rhc G)ntact,^ Li.ctr\c Lr$ ri)r rh. nll,,trin! rcrv (Ss.7rll5'
<br />tru\irc\\ rDd Ptrnc\si(in Co,lr) Ary Cil, or (i8 y whi.h rcquiru\ r Fnnir r) cotr(rucr. lllcr. i |]s,vc, dctrhlirh ,t rNir uny
<br />{ru.rur.. nri,nn, ir\ is\utr cc. ilso rcquircs rhc apdiu ftn st.hFnnir n) lile! \i3nc{t (rrrntir rh.r hcorshc i\ liccn\cl Pur\u Dr
<br />lo rhc pnvision\ ol rlt c()drr.tr's Liccn$d ltN lchrPr.r t- Gnntfi.i|! wirh S.ction 7(xl) of Diri\i( l olrhc hr\ilc\r anJ
<br />Pn,rrsnnr\ Curlc).r rhd lEor \|rc l\crcmpr rl,cr.frotr1ui rh. hr{i\ li,r th. rllcgctlt\!mP!n)n. ADyviolnhotr.lSccli,)n7(,.11 5byriy
<br />rmli.!nr r r p.mirsuhjccr\ih. arlli., r. r.iril|tnilryolnot nFrcrhrn iirc hundrcddoll{\ l$5(x))
<br />I. at o*tur of rh. pmltny. or my cmtlolcc\ sirh slgt\ $ rhcn {tb co$Pc.$lt,n. sill du rhc solt :trt lhc srr!@ i\ nor
<br />ir.ndcd orolltrcd,nrslc{S(7(x.1,Bu{incsnndPn,ltssionsCodcThcOnnrtror'\t-iccn\cl,!$doc\norJrityk,ttruwndol
<br />rhcpmFny *hu bur[s .r iqr {nc thcron,, u *lx)&ts\rhnb*hi'.scl,orhcrsclfoirhr.tr8hl,i\orhc'otncnlpbvc.s.
<br />prolidcd rhrr su.h nnffrvcm s ar mr irrodcJ or orctod for s lt I( h)Ncvcr. lhc builling dr n\rmvcmnl is sk] + irhitr oic y.u
<br />olcoq,hrhn, rhc O*mr BuiHs will hlk rrr bu.dcn otrrovir8 thlll lEor \hc dil mr hiu or inryovc thc pmpmy for $. pulr.* f
<br />-,.0sosnsotrhclDpcnt.a'n.r.lu\ivcly.otrtldingwirhliccn\cdcona(ttrsr.consruclrhcPmj.crls..70'14
<br />3u!im$
<br />anl Phfs\bn Codd: Ihc Cotrtrctoi \ Liccnsc I !u dod\ ior rtPlyro 0no*ncrolProp.nysho hurldsor inlrcvcs rhcrcon
<br />.trd who $ntrucrs li, ruch p(,rc.rs with d c.nridon9 liccnscd puru!.r t,rh. cbntn.ktr s Liccnsc l;'*)
<br />_l mcxcmfl udcr Sccl
<br />laatrE&r:coMlBsArl!}!
<br />DECIdIAIIO!
<br />I hcrcbt uffirm un&r pctrllry of p6j!ry orc .r U. follor in8 d(la.lions:
<br />I hav.:drlqill nun rir.Cc iti.r,c otCo {nr b Scli t.surc lor q orkc^ 6mpcn{drion, $ pn}vidcd r'o'btS.criotr]Tmofrhc
<br />lltxn Culc, r(tr rhc p.{omDnc. ofllrc work lor qhih rhc,,cnnl is tsucd.
<br />I hivc ond will Minllin *orkers .oo!.ns.rion insurarcc. N rcqlirc{ hy s*ri.n ltu of th. btor Cod.. for rh. P.rfomre ot
<br />inc wo* for *hict lhis limit is iseEd. My wort6' onpcnsolion in{ramc cmicr sln poli.y tumt d @l
<br />PdicyNrn,hlr
<br />-Lxlnc\:
<br />I Nniry rhd in rhc rcriorrone oa rhc work ror which rhn pcrm n hsled. I rh{ll nor cnlloy any |lc*on in any mdrct
<br />s s ro b.co'E slbFr ro rhe uolknc mn!.nsalion hss of Calitumia. ud t8@ lh.l if I should lxcom subid lo llt
<br />workcr comtcnsarion Imlisi.nsofScdion 3?00 ofthc titnr Codc.l shtrll, fonhwilh mnPly wnh rtn€pmvrions..
<br />WARNING: Fsiiurc ro surc workcn co.{Enn iotr orcms€ is unlnwfui. and sholl suhicr ,n copk,}!r ro aiminll lcdlrir and
<br />ciril fin$ up ro onc hundrcd lhols0nd dolltrs (SI00.0OO). in lddilion to rh. cosl olsmr*n$ln'i. dotr8cs as pmlil.d t rhc
<br />LIcENSFDC()Nrll (1',ftlll
<br />Dr:cLr.[aIIqN
<br />I tudhy im n uM.r ri.ntrliy ol pcrjry rhrr I Mr li..n{d u.d$ f)risirr ol ChaPro 9 (.omnEncnrg 'irh Sccrk,n 70(x) r .r D'viion 1
<br />of rh. Bdsi.r*md Pr,fc\snnls Codc. Md nrylircnv i\ rullro.crtrdcltcr
<br />a7-o 'lo \o Sz
<br />I
<br /> PPI ICAN'T DF(:I ARATION
<br />I lBrh, rfim undrr l]ctrrlryofp.rjury onc olrht lalhsnrg d.cl.rrrions
<br />D.nNlirion Pc nir\ Asb.io\ Norifiurion tr.dcrulRcaulari.trs ('lirlc40, Pd6)
<br />_Rcquircd I.(d.f Nollrr.tiotr
<br />-l
<br />.cnify rh,r rhc fcdcml rc8uhliofls rcgodirg a{Bros rcn,,al arc nol aP[,lkab!: lo rhk pmia1.
<br />-l
<br />csrity rhar I hrv. ,.dd rhk appltarion .!n shle filr rh. ihovc inlormlion is .odl. I .gG lo comPly wilh lll cnv and coulv
<br />ordiMtrccs ond Srare ljsr ebrirg ro hoihi.S construclior ad hcrchy nurho.izc Elmsc arivcs ofthh Cny and Colnlv ro c.to Won thc
<br />lhrw mntioEt pot,cdy lor insp..r
<br />Applicanr or &cnr Siguru,c
<br />.:ry o 6lt+ I 4
<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 />Rouqh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Ranqe
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />Openinqs
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rouqh Mech.
<br />Final Test
<br />Meler Release fi^
<br />FINAL -7/t7,/t{/rf-\-t^
<br />Notes, Remarks, Etc AJ (,(./
<br />MECHANICAL-INSPECTOR RECORD
<br />SNdon 1076 of lfie l,tnr C.dc. i.lcrcel ond sllomy\ tes.
<br />o,,,,oC/L+l 1g nor,-,, (
<br />caNir8llquNrEruxli-&GE!.cl
<br />I hcrby lfir undcr lEnrlly o f perjury rh,l rhcru is a consruclbn Lndine ulc,ky for rh. ,'sfomEncc 6f rh. sork for whkh thn lamn h
<br />hsucd (Scc 1097. Civ. C.).
<br />GnJcis N!'m:
<br />-
<br />Smoke Detectors lnstalled
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