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APPROVALS DATE ID/SIG.COMMENTS OlryNE-f, BI'ILDEX DELCARATTON
<br />I hcrcby smrn un.Lr p.mlly of Fdury ln,1 I m cxcrul fmm lhc Corh.loN Lkcns L{w fo.lh. followinS @$n (S.c.7031.t
<br />Blliness ord Profcrsi'n Code)r Any Ciry or Counry whi.h Eluircs a lcrrir ro.onn .r. .lld, iqrtuw. dctuhh or E|l€n dy
<br />slrucnm, Fior lo il3 issume. alm EquiB lhc q,plhdl for iuch Fmir lo nle r siged star.trnr $ar h. o. shc h lic.n*d purornl
<br />lo llE FDvhkinr of dE Conm.br's Li.c.$d Lir (Ch.prcr 9, Conftmin8 *nh Ssrion l00l) of Didsion I of rh. BBin6, a.d
<br />Pmfcsions Cod.) or lh.l h. orsh. is.x.mpl lleElrooand E b6is lo. rhe rlbe.d cxcnption. Ary viohtion of Selbn ?0ll.l by.ny
<br />aptlicafi for 6lcmir slbjeds rhc altlica b a.i!il pcnalty oa nor rcrc thln fiE hunded dolld {1500).
<br />-1.
<br />aj ovncr of lh. Flpeny. or m, cmployes wirh wag$ .rEi $L conqxnsri.tr will.lo tlE w* .,n E slrBlE ii ml
<br />imcndd or 6fr.ed for sk (S€ 7014. Bositu3s and Prctesions Cod.: Th€ Conreld r Li.c.c L,* does mr qply lo M o*ncr or
<br />$c pmFrty who 6uilds or iryma lh.on. ad who dB Mn qort hinsclf or ltrslf o! rthlsl hh or hci own cttoloyccs,
<br />pmvidd rtut .Eh iq,m\tmils @ mt ht .d.d orotrc,ld ror sL, ll h.wE rh. btrildi.g o. i.p.owmil i. $ld rilhi. om )€t
<br />of @rpldion. tlE Omr auihcr wil trE tlE hrd.. of povinS lnlr h. or sh. dil rel build or inprcw dE pDpcny f.r lhc porFe ol
<br />_1. s.ow.eroftu popcny, ancicllsie.lyconrEclinBwnh liensd contracror ro.on\mcr rh€ poje.r lse.7044. Bu\inc\s
<br />and Eoftssion Codc: Thc C.nlr!.itr\ Liccnsc tiw dms nor dlply ro anown.r ol!tuFdy who builds or improwr rhtrcon,
<br />d.d *ho o tuds fttr $.h l,oirr\ *irh ! ConrEcro(s) liccned I'ununr ro rh. Conlncrolr Littrs L,w).
<br />-l
<br />m ercmfl und* Sftdo
<br />_t hatc qld will Minr.in r C.natuarc otcotrc ro Sclf.lBUE ao( wrtc6 6mpc.slrion, a ,mvidcd for b, Serio. 1700 ot rr
<br />Llbor Codc. for lh€ p.rfoM. of llE *mk for which lh. ,shil is i$ucd.
<br />I hrvc and will mai.trin eorkcB .onFm0rion in\uraft., ar requncd by S..riun l7(XJ of rhc bbor Co&. fo. lh. pdlormm ol
<br />-;
<br />ilYr*"
<br />-mrisrrion i'Nuran...drif drd lbricv trumhc, fcl
<br />-l
<br />ccnily lh b
<br />'hc
<br />p.raormmc of lhc wo.k for whkh lhic pcrmir t issu.d. l shall nol cmploy any pcr$n in ey mMrcr
<br />$ &s ro h..oft slbisr ro rl'c *orkcn'compcn\arion h,s of Califoni!, Md 4se rhur i, I should b..om !!bj..r ro rlx
<br />eo*.6 smpcn{ ion povhi.nr or Sdisn :lT00 6r rlr Lrnr CDdc. r rlau. fo hwi'h conv,ly wirh rh.$ tmvirions .
<br />WARNING: r{iturc to wurc qortcm omp.nsllion covcnSc is unhwtul,shnll ul+cr nn cnrDloy.r l,'.ri'ninJl Fnrhis rnd
<br />civil fincs up lo onc hundrcd thousnd dollars ($100.000). in addilion lo I sl ofconrr.nsolion. daroscs rs tmvnl(l for lhc::it;ww,;
<br />IIII]NSEJLCONI3AEIOA
<br />DECLABA.IION
<br />I hcohyriftmudd.rIlL lrtoflxrjxryrhrr Ln n(n{d trrkl.r lrrvi!.nol (hrrrcr 9(.oimrn.ing qirh Sccrion 7nX)) olOnisi n:l
<br />ol rrr Bu\im\!u Prori\\ions Codr- {kl nry liccn\c i\ h tulllorccruxletricr
<br />r -, d ,**.n,^*,,:/o3,2 ?u2
<br />D.b.' 4 /Wy/{.o*oo. )'*
<br />IONiIIIJEIIQNI,TNUIN(;IJ'N{jI
<br />hsucd(Sc. l(r7, Ci C)
<br />ATILI!r!NLDE!"A-8AI!O!
<br />I h+r6l rninn u ndc. Jrnrlll-..llrrlury oN.irhc li,lkrvin! dcc[rrr(nr\:
<br />D. rlirr{ l,cnnir\ df,lor Nooll.loi r.d(fu|RcFulxrut\ ( lirl. ]0. hn6r
<br />Rcqun l.ricrolNorifi.rli,n,
<br />_l ccdily rhtrt rhc icdcralrcBultrlioB Eg0ldin8 asbcsbs r.'nordl$c nol amlic$lc ro rhh pmrccr
<br />[|[.nnr,*, , r*., *n+nri.dmn rd
<br />I ordimnccsrndSlorct]wrrcl,rine'ottrildinEc,
<br />{arcrhdrhc $rc inturmarior is c.nccr I asR b c.nfly wirh rll Ciry,nd Coun'y
<br />and hclcby aulho.i7. rctEscnrariles olthn Cnyand Coun'y ro cnro uF,n rhc
<br />ubot ftnlioned popcny for insp.clion purlxMs
<br />Aptlirxnr or A!.ir Signrr!
<br />p*t.,*\Nb,),r\ y') L) NA5)lEM(
<br />ui7
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Compressor
<br />l\/isc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rough Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Range
<br />Other
<br />Hood
<br />Type I Hood
<br />T ype 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 />R ough Mech.
<br />Final Test
<br />FINAL ,/,k/lb <},#6
<br />Notes, Bemarks, Etc
<br />MECHANICAL-INSPECTOR RECORD
<br />Furnace
<br />Meter Helease
<br />]{oaf,E&ul.t0ltfjNsAll0!
<br />DEC!.ABAITqN
<br />I hercby lnirn !n.tc, pcnalry of lcdury one of thc f{nk'wing dccLu{donsl
<br />I
<br />tt
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