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APPROVALS DATE tDifc"_COMMENTS <br />Appliances E' <br />Evaporative Cooler <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes D ryer <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />F.D. Dro p Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release / <br />FINAL 1/7n/,4 lft v6/Xt/t <br />Notes Remarks, Etc.7 7 -.._ <br />-)1 <br />OWNER BUILDER DEI-CATIATION .t hd.by sffim und6 Fdhy of Fjury lh,l I m .r.npl iioo lhc ConlncloR Li...* tle for th. follosing t@i (5(.7011.5 <br />BBiods ani ftoaeion CodG): Any Cny or Cou,rty wiich r.qur6 a F,nil to co.gtuc1. alla, i8pror.. &!mli!h or r.rd a;y <br />ntucto.. priorro il3 isec, .lso r.qutd th. .,plicer for iu.h pq,il ro filc a .igtr rl sllImor rll,l h. or 3t. b licqB d puMrln <br />lo lhc Fovieioc of th. Convicld 3 Lien$d riw (Chrfld 9. CoMmcing wih Sadon 7000 of Divilion I of {ic BEItB ed <br />Prcf6ioN Co&) or fill lE or slE ie cinpr rhs.{rom ed ln€ &sis for rhc all.Sed cr@Eiotr. Ary violalion ofSdliotr 7011.5 by my <br />.pplicanr ror . Fmn iubjer5 ln lppli@r ro 6 .ivil pcMhy olior oorc rhe fiv. hurtu dolla (1500) <br />_I, a omd of tc prop€ny. or my mplor6 with ws86 a rh.n $t cohp.nsarion. will do rh. woit od th. stdr b tur <br />intqd.d or otrdcd aor s.l. (58.7044, BEitB ed Proli6sioB Cod.: TlE Cotua.roas Lic.M L.w doe .or spply to d own6 of <br />th. poFly who hildi o. imFrv6 dEall. Md *no d.€ st srt hin!.lf or hGlf or ltrcu8h hi. or ho om dploy.6. <br />povidcd lh.t sch idFowl!e@l imsd.d orolH l sL.l[ toxrs, tt buik]ine or inFouE n sld wnhir oE rB <br />ofcompLlior', tlE Owrq BuildE *i! havc $e hrdd ofFoliig tl'a h. o. sh. did mt tlild or imFo€ thc poFty for dE purpos ol <br />-1. <br />d oM6 ollh€ pNpsry. m qclNivcly conrra.tiq wirh licdr.d .onhcto6 lo col(rud rh. pojdr (S4. 7044. B6ind <br />&d hlfsio. Cod.r Th. Conlraciolr Li.ca. Law do6 rcr ,tply lo m o* nn oftroFny rho b!il& o. inpror6lha@..aid ,ho cootrcls for such proj.cls wirh . CotrtBclo(s) lieos.d puB@r lo lh. Conrdclols Lic.@ Law), <br />_l a.€rcmpr Md6 Sario B. & PC. ao. rhir r.aon. <br />.E985EB::CqMEMAIPB <br />DSC!.68AUQ! <br />I hd$y aflim undd poslly of pqju.y on. ofthc lollowins d..hEiioNi <br />_I ha!. dd will roinrain . CarifEar. otconsr ro S.lf-lnsurc for rvorkdt @nD.n$io., a p6vid.d lor by S.qion 1700 of thc <br />-/ <br />_l c.nia, lhai in lh. Fhmanc. of rhc wort ror which rhis Frnrn is issEd. I shall nol nploy &y p6son in any ftd.d <br />so 6lo b..om. subjel lo lh. mlt6l compaeliof, la\6 olc.lifomia d rgBind if I should b<omsubj4t torlE <br />wo,(6 mmpcB.lio, prcvisiosotsslion 1700otth. bbor Code.I sltrll fonhsnn.oDply with thok povisioN.. <br />NARNINC Failur€ lo srrc *orkc6' compsBalio. corem8. is unla\uful. and shall subjccr an enployd lo ai'nin.l p6uni6 md <br />civil fr,6 op lo onc hundr.d rhoMd dolla (t100,000), in add l. lh. cosl ol comp<Nlion. d@B.s 6 prcvid.d lor th. <br />s(rio.1076 orth.l,borCodc,, r€q d rhornq s a6.x <br />DPCIJEAIIaU <br />I hmby aIIm udd Fn iry of pqjury tha I @ li.@.d u(k Fviiion of ClsB6 9 (@Mins wiri S.dio. 7000) f,oivi3ior 3 <br />ol thc B$ina ed PbfdsioB Cod., and my Ii.ce i5 i, tull rorcc ad .fiftr ( -r-o*/) <br />* <br />tarux-ucr0rLltDtNc_dctN(r <br />I h6.br allm undr Fnallyolpqur)-'rhar rh.c t n coonrucrion kndiu ascncy to! rhe p€afonrancc orrh. \ort lir shich rhis psnir is <br />isstr.d(s.c .!097.civ c) <br />AIII,ICANLDICIAAtrIION <br />I hg€t,y nmnn unds lmrl'roapdjury on. of lh. (nh*inr d6llrattuns: <br />Dcmolirion PeniB-Asb€sros Norificarioo F.dsal Rcsulalions (l itlc 40. Pan6) <br />-Rcquicd <br />lf,tta o t Norificarion <br />-l <br />c6ri8 lhd lhc ldi@l rcsulalioN Eg6dirS abeloi rdord e nol rppli.ablc lo lhi! projel <br />crlity thal I nalc @d $t a9llic.rion ad slal. thar lh. ab.v€ infomarion is corccl. I conply*ilh.ll Cnyand County <br />ed Starc La$ Ehliry lo buildinr codtucr iotr rrd hEcby auihorizc of this Cny .rd Courly lo drq upo. lh. <br />.ho!c holio.cd propdy hr <br />Applicanr or Agdr Sistururc: <br />MECHANICAL-INSPECTOR RECORD <br />Metal Fire Place <br />Furnace <br />lnstallation <br />lhc psfombc€ ollh. wort for which lhc pmit is issu.d. <br />ind will mainlain wo,k.rs 3700 of thc l,bor Codc, lor th. Flolrue ol <br />PolicyNumbq: r Erpir6l