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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG,COMMENTS OWNAf, DUILDER DELCARATION
<br />I hcreby a,Iun undcr Fnahy of !..jury lhar I m crcm frch rhc conr*lDu LkcnE tiw fo. lhc tolk wag usn (s(.?oll.t
<br />Blsincs nnd Pmfcasion Codc)r Any Cir, o. Co!.ry which EluiEs . Fmn ro @trnul, ald, ialpovc, (bmlisnlr E?ln My
<br />sldcle. |rb ro ni ir.u!e.,Lso mquiEs lh. spplisr tor such Fml ro lilc. riSned sdecd lnll hc or shc i liccfl$d IJur$Ml
<br />ro rhc lrovisions of rhc Conlrecbr.. Lien*d Llw (Chlptcr 9. Comftrins wnh Sccrion 7m0 ol Divi.ion 3 of ttrc Business eld
<br />Pbf.ssioN Codc) or th{l lE o, shc is e&nDr th.Efron r.d rhe bask for ftc {lleg.d cr.mplion. Any viohli.rn of Selk n 701 L5 by !.y
<br />lpplicld for ! Fmil suhjch llE ltpltunl to !.ivil p.Mhy of ml Drc tho fivc hundtd dollus (t500).
<br />I.r\ usicrorrhrl,n)F*nt.ornrycn oy..swirhwiscsdsrhcnvrbconrpensJrior,*illdo f,workurlrht(mtucisnor
<br />i' cd.n or on'cicd tu qrlc ( SN 7OH. Businc\\ rnd Pron\\tnN Con. Ilr cl,ntrrlm s I -iccn\c I js doc\ noi trpdy ro rtr owrr ol
<br />rhclfr|xny *ho hikl\ .r nrrrn*$ rlr6n n,xl whh tu\ u(h qllt lrnn\clr or hcr{ll o. rhrcugh his or hcr ou n cnrpk,rcc\,
<br />pruri{lcd rlur such iqrr^rm.h rrc nor inic Lrl r oficql tur {t lf. h'*orr. rh. huitliry or inll]n*ornr i. r)ti wirlrir ortr }rd
<br />of$nrplcrk r rhL()*trcr Buitlcr sill hnvc rhc hu cnofl)n)vir$rhdr h.or$cdil norbuill ornnpn,vc rhc pmr^-ny finrhcptrry){oI
<br />Ll r\ n*trs or rhc rr)ltny, r r crclu\ir.ly c!fta.un! *irh li..n\cd .otrrr.kn n, ..trnrud rlr pr+cr lscc. '7(Itl- BunNs
<br />xl Pn)larsi'nco c lhcContra.ttr \ Liccrsc l-uq docs nolrppllri N ouncr ol nn'nc(r sho hlil \ or nnprt,vc\ rhcr.oD.
<br />rnJ wlD corrr \lbrsu.hpn)lcc(wirlraCo ra.k(\rlic.iscJ,trAutrtrrk,rhcO fu.rofst-Nnschq)
<br />I hcrchv xhnn uf cr
<br />^-nllry
<br />of Eaury om of rh lalb$i',!
<br />-l
<br />huve ard *ill minldin a C.nifrdrc of Cotr{ (, Self lBure tor workdc omFnslior, I p6vid.d for by S*tion 3700 of lh.
<br />Llbot Codc for thc Frfomtue of tu adl aor whi.n lh. Ilmn k isslcd.
<br />,! hlvc ondwillm0inroi. workcn compcnsutkn insDran... as EqDircd h, Sstion 3700 ofltc L,tor C.dc.lor rhe pc.ro.nrec of
<br />rhc work lor which lhh l,emil is issu.d Mywork.* .onFnsrion insurlnc. @ic. !d policy nlib.r e:
<br />-l
<br />ccniry lhat ir lhc pdforMnc ollhc wo forvnichlhhF nil is irsucd,I shlll not cnptoy lny I,c6on in any m.n.r
<br />s !s ro bcom slbirl ro rlE *o*.a clmFnsdion hws ofcllifomi!, and asd |hll if I shotrld bccoB.ubirl ro th.
<br />wortcs' conwns.lion povtiotrs ofSelion 3?00 of lnc t,bor Codc.l nElL fontwirh$hrl, snh rh.e povhions..
<br />WARNI|i(; frilur t, {curr workcB'.u rt'cisJrt!1 co\crrf. i\l. &d sh0ll subirl an cmplorr x, oidinll ltuUi* utul
<br />civil fiic\ rp b oic hrndrcd rhou\ dolles (SIm.O(X), in dir to lh. .osl of coq,.nsalion. dam8.s as ,rotided fot'thc
<br />Sc.rn 1076 ofrh. trtlr Codd. iNcrcst.nd nrkxncy\ f.c
<br />DECTAIAIIII!
<br />I hcrcb, .oim un&r Fndly of pcriury rl[l I m lienssd und.r Fovision olctuprs 9 (onmeing wth Serbn 7000) of Divlsion 3
<br />of th. Busircss .nd Pmfssims Codc. ed my li:.ns ir in tull foE .,n cfiel.
<br />l,xrr
<br />CONSIf,JJqIIONIEIDINIi.AII'NII
<br />I hcrciyritmuDdcr F-.!lly ot Frjury rhi rnerc i\ rco.{tucri,n kndins sli.ytur rlrtf,rronnr.c ofihc $ort lnr whi.h rhi\ pclnrir h
<br />issucd (Sc..3097, Civ. C.)
<br />ll[fllcaNfDlict B,ura!
<br />I hruhy dlnmundrr p.nrlry ofp!rturrotr. ulrlt foll.$i"g {lrlffari,,n\:
<br />l*trFIiri, l,{nnir1 \h.Ioi Nohicdtrin l.dcril RcgtrhrMr\ ( rirlc 10. Prnr)
<br />-Rcqtrtcd
<br />l,crlcr or Norir,crrii,n
<br />-l
<br />enify lh,r rlt f.ddl Eglldions Egarding aibcsros rcmal e mr rpplt,bh lo lht lmic{l
<br />\l c€rrily rhsr I h."c rcod rhis aprlicarion and surc rhar lhc otnvr inlormrio. is corel. I r8,e ro.onply wnh sll Cit, lnd Couly
<br />ordnrmcs and SbE kss ELrine ro build rucrion. ! hcrcbyauthrnc rcPrssntaliecs ofrhisCny.nd Counryto cnl.r ul[n lhc
<br />abovc mnlioEd pmp.ny Lt
<br />Aprliclnl or &cnl Si8nolurc:l) r
<br />*T(',:
<br />?>eooo,,.t
<br />{fttleu
<br />Appliances
<br />Evaporative Cooler
<br />Furnace
<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 Dryer
<br />Residential Ranoe
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />Openinos
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.
<br />Final Test
<br />Meter Release
<br />FINAL ( -t-t-tb J)"t:ft/t0
<br />Notes, Remarks, Etc.
<br />Metal Fire Place
<br />I
<br />-, qfraf\
<br />LiarcChs: I tce Nu,[er:
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