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MECHANICAL-INSPECTOR RECORD <br />DATE IDiSIG.COMMENTS OWNER BUTLDER DELCARATION <br />I hftby affrm undd p6ahy ol pdjury th l m qchpt frlm rh. Con$acloR Li.ds Lae lor thc lollowine rce! (Ser 7031,5 <br />Brsin6s md Profsion Cod.)r Any Cily o. Cou$y which rcquirG a Fnil lo .oBlrucl, ,llq, improvq damolish or Epan ey <br />sttucluc, p.ior to irs isuMc., .lso requic lhe applicad for such Ff,ril lo fil€ a sttud stdrddt rhd he or shc b lictucd pcuirn <br />to rh. Foli5ioB ofrh. Coalrsclois Lic.n*d Llw (Ch.pie I, Co@@cing wit Sdrion 7000 ol Division 3 ofthe BNinds &d <br />PDf.sions Cod.) or rhal he or shc b €xmd lhdeion.nd fi6 b6ie for rh. allcscd cxdpdon. Any violalion of S6tio! 7031,5 by ey <br />applic@i for ! Fflnil subjdis lh. appLi@r to a civil p@aty ofnor norc ln& iv. hu.dr.d dollG ($500). <br />-I. <br />d osd ofrhe p6perty, or <br />'ny <br />€nplorB wilh was6 a rhen sb cotopdaaion. vill do th. wort a4d fic nructrc is .ol <br />inlod.d or o fI6cd fo. slc (S-.r044. B6inGs ed Pof.ssioB Cod.: Th. Conlr0ciols Li.o* Lrw doe nol apply lo m omd of <br />th.p,Dp6ly rvho hrilds or inp,ov6 rh@n. dd who do6 su.h wrt( hins€ll or n6ell or lneust his or ho oM oploy.c, <br />provid.d rhat su€h imprcvmols m nol inlsxt€d u olIqd tur sL. lf, how6, thc buildinr or inptomat ie $ld wilhin one )@ <br />olcorykrion, lh. Otrnn Brildd will lBw lt. hdo of prcvi,! $d hc or sh. did nol btrild d imprcw th. Frpary tur lhc purpoE of <br />I. a omr oathc prop€ny, an €xclnsively contraclinS wilh lic.ru.d co.trcloE lo conslru.l the pmj6t (S(. ?044. B6in6 <br />ed Proftssion Codc: The conlr.crol s Liccnsc Law do* .ot apply ro & owrd olprop(ly who build! or inprov* lhro4 <br />and who o,nmds lor suct projeG with a C.nir?do(s) Ltdcd pGuMl ro rhe Contracror's Licds. Lsw). <br />_l m cxmrt @dd Setion . B. & P.C. forrLi! l@$o. <br />Drr.:_ Ond6:_ <br />WORI(ERS' COIIPENSATION <br />DECITEAIION <br />I idely aflim !.do Fnalry ollsjliy olc ofthc lollowiie dcleaioB: <br />_I h.ve dd wi I I naintai. a C.ni fical e of Co nsdr to Sell- Insurc fo. workeB conrp.Nalion, a prolid.d for by S el ion 3 700 o I lh. <br />Libor Cndc forlheprlom ccof thervort for which dre pmil is isucd <br />I ha!. md will nai6rai. work..s co,np@alion i6dance, a reqrned by S(rion 3700 of lh. tjhor Codc. lor lh€ psfomdce of <br />th. work tor which this pmir i! islued. My wortm codp@erio, iEuoc€ cdie dd policy nmbs m.i <br />Policy Nmba: Eipir€ <br />I c€rlify thal ir {h. psfornMc. ofthcwork for $'hich this lnnn is issu.d.I sh,ll nol mploy any pmn h any nund <br />$ 6 to b€.o@ subjd lo rhc srtd' eop..srion las ofcalilomia, dd agrc rhd ifl should bdomc ,ubj4r to rt <br />wort6' .onp.Mlion pbvisiod ofsdtion 3700 ol th. L.bor Codq I str.ll fodhwnh omply sith rnoF provlsioa.. <br />WARNINC: Failur€ ro su. yorL6' coftp€sation o!@s€ t unlawtul dd shall s!bje.1 & <br />civil fin6 up ro otr€ huidr.d rhousd doll$ (t100.000). in addirion ro the cd! ol conpdsario <br />Seson 10?6 ofihe kbor Code hlffiedlhomcy' <br />o,,". q/rr/y'? n*u*",. <br />ucEtt!Dlla-t-B{_ra"B!.ug ltrll1 <br />I hreby allm unda p€o.ll, ofpdjury lhal I m [eB.d udn Flvisioo ofcbaptr 9 (com€ncins with Sdioi 7000) ol Divhion ] <br />oa thc Bui.d ed PoldioB Codc, ed ny lic@. i3 in tull hE. &d .fid'. <br />CAISIAUCII9IItrNDUCAGENCI <br />I hdcby am.n unde pcnalryolpqurynEl rh6e ii a coishrction kodirr agen.y lor rhc pnaoanan.. oarhe work aor \ehich this pa:nn is <br />isiEd (Sd.1097, Civ. C.) <br />ATTUCANfDECI.ASAIION <br />I hfrib, sIlm undd pmat! oapcrjory onc oa lh. lollosins docldalions: <br />Dc,nolirion Psnnrs-Asbetos Norifi carion Fedcral R€sulalions (Tirle 40, Pea6) <br />-Requted <br />tdr€r olNotifi calion <br />:/ <br />-lcdin <br />inar rh€ lcdd.lreul.rrcN r.,:edinc dbesros r.movrl ee nor opplrable ro rhB protd. <br />I coriaylh.t I hav.,odihh applicalion a stale rllltl tlratDlc inlonnarion is I a8!e to omplywnh all Cityand Coury <br />ordinanc6 dd Slale t!* Eldins ro buildine coosrruclion, &d hercby -::."'^1,:)y';:*^" <br />above hdlioned prorErly lor insrection '7?-^' <br />Applica o, Agerl Silnalure ( <br />Pm k nrnP rFinr, <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. E quipment <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 />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />ll <br />Roush Mech. @DWt 1l/fuyya c t/0{/? -?/fe <br />Final Test <br />Meter Release A\ <br />FINAL 0-79 <br />tes Re arks, Etc.\V <br />(&b era"d .uf e 8Z obr ivsulc.(oq . t/4(l hth <br />ot4c A ,al a.dc *'tt. b'"tc, ba 1.1*..v <br />APPROVALS <br />-------r-----=