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MECHANICAL.INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER BUILDAR DELCARATION
<br />I h.6by uoirm uod( ncn , r)a pcrjury lhal I M cx.nrr itom rhc Conrtuon Liccnsc llw aor ilE rollowinS rc.en (Se.?031.5
<br />Busi.ers .rn Proa.sion Cdc): Any Ciry or Counrt which r.quircs r Fni ro co.stdcr, altd. imFovc. &mlBt ., qran any
<br />srtucl!rc. prior b ns irsu!re, ale rcqliEs lnc arrplicanr for suct lcmir ro fik , sigtud rr.rcm rhll h. or shc i! ltcnsd pur$mr
<br />ro thc pmvision! of rtE Colkftbls Lic.nscd hw lchrt .. 9. Conencin! vith Sslion ?00O of Division I of rhc Blsin€ss and
<br />Pofcsions Code) o! rhar hc or shc n.rcmpr rhcEfon&d ttE &sh for rlE llks.n crcmprion. Any viohrionolSel6n 7011.5 by any
<br />lIplic! for a pcmir subicts rhc ryplica.r ro a civil l,cmlry oa not mrrhM fivc hundod doll&i (5500).
<br />_1. &r owicr of rhc Impcny. or By enqloyes wirh wrgcs as thcn st com0cnsatioi, qill do tlr *dt ad fic $nxrm i\ rer
<br />i ..'(H or orcrcd ftr sk (S&.7Ot4. BusiNs. aod Profe$ions Codc: Thc C.nt.a.ror3 Lic.ns. lnw docs nor a,lply lo afl ovncr of
<br />lh. p6p.ny *ho hrilds or i"pors uEsn lrd who dB (h ed< hins.lf or hlMlf or lhmu8h nis or hcr osn cmrlo)ccs.
<br />pmridcd ltul such in,,omnh @ ml hlcf,d.d o.ofi.Ed lor slr. It tsftE th. hoildinA or i,psrcmnr is $ld q hin ^nc r&ofon{ c.ion.llE ol,ftr auilhr will hlE llr tordcn orr.viog ihd hor $h. dU m! t ild tr inplorc 6c pmpdiy ror dr purpos or
<br />l. ( own r of rh. IrNFny. am ex.luriely cool@ri.e wirh li.en{d .oore(oR l0 ois4cl llE p,!j.cl (Se. 7044, Busims
<br />and PDfcsioi Codcr Tnc Contretor's Licensc L3w do.s mr 0ml, b on owncr of popcrly sho builds or idprovcs rh.ron.
<br />and who conri.h for such I'oj(rs wnh a Corrtulo(t licenscd rlnunr ro rlr Coorr&lq s Lidnc Lr{).
<br />Irrcxo \, !iJc' Scrri,nr ,B &l( nnihAroxnnr
<br />"*ffi*
<br />I hcnby.fllrruido r.n!lr!of Injuryo.c ol th. nrbwinS d..limrion\
<br />Ihrvcmdsillnuinrlin!(.dilicltofCon\dnrn)Scllltr\urcntr$orkrBro{t:n\ari(nr,rsBrvidcdlnrhySccrion3?(xrollhc
<br />litxn Gxlc. ti,r rhc Frlbrroncc orrhc sork t{rshichrhc n rnril ir hsucd
<br />dsc d tr ill mrin,in wolkcn compcns.riotr imtrmm., as rcrtnircd hyscclnn r7(xroIlh.I:rh.r(-ode. ror rhc ,olontuncc ol
<br />on{E.srion irsurm. tricr and policy nudbcr N:
<br />dro t+/z-a
<br />-l
<br />c.nili fiar itr rhc ndformncc otrhc sork tor which rhis rE d'r ir i\sucd. I .hall bor .rploy .ny FMn if,ony maflmr
<br />s 6 to bccom subrc.l lo lh. *nk6d on{rc.elion loss or Cdifornia dd o8M lnd if I sholld beom suhjel h rh.
<br />mrkcB con{rn$rion pmvirbns of Solion 3700 ollhc tihor Codc.I nElL fonheilhon'ply wilh lhos povnions.,
<br />I{ARNINC. Failu,. ro s@ hrkc comt nsari.n c.vcdgc h unh*ful. a.d sholl subjer M cmt'lorry ro aimiEl FroIi.\ ind
<br />civil lincs uD h om hundrcn rhousand dolh^ (!100.000). in addition ro lhc co{ or.omp.nslion, dam8.s as pmvitn lor tlE
<br />s<xon 1076 or rl$ Ldor c#. inrc(n
<br />".", //zr/zo or**,,{
<br />ucElsEt}.cllNrna(rgB
<br />DIIIdEAIJIIN
<br />I hcrcn, sfiir lndcr Dcnalry oa !cr.iu.r rhal I !m liccnen lndcr povisbn .f Ch+rd 9l.onnrncing wnh sccthn ?uro) ol Divkion l
<br />or rhc Busincs.nd Proftssn,ns Codc. and myliccnsc i! in tull Lreadcilccr.
<br />,**.r*,,g&tezD /e&*, //r/=D."",*,"".6 +r-
<br />ca! algrrcNlxNDllc]{r-0li(I
<br />I hcruhlrllt'nundrrponxl(vo,FrJDryih r rh.rci\rcotrnrucrimlci mg !cn.)turrhcFrtrmnn.colrhcsor*trshi(hrhi!JEnnili\
<br />ir{'cd lsc. .loe7. Civ c ).
<br />APII.ICANLDECIJaAIII]N
<br />I horht ,frnn under p.ndlry oa Icrju.y om or rh. followi.B deln.,r ions:
<br />Dcmlilion Pcrmits-AstEsros Nolific ion F.d€ru1 Rcsohlions (Tille tlo. Pen6)
<br />Rcquift'd tr(cr of Norilirtion
<br />llt*nrr rhar I hlvc.cad rhi( lpplicllion anJ drt lnlrrh. oh,v. iafqrorn,n is.omr. I a8rc r..onrdy wilh.ll Ciry0nd Arunt,
<br />Sralc tips rcl"tins to buildins consrrucrioa,ond hcrchy lurhorizc rqrLsnrxrivca or'hk Ciryaid
<br />ahovc nEntioned l,m!cn, for
<br />Aoplicanl or Aelnl SiSnatu
<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 />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 />Openings
<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 />aln\?0 ?-tp)6vilr'
<br />Notes, Remarks, Etc.
<br />APPROVALS
<br />Smoke Detectors lnstalled
<br />FINAL
<br />z? l rzD
<br />Lad.ft N.B:
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<br />trnd€ls Ad&Es:
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<br />I .cnify th lhc Ld.hl nSulnrions R8&din8 nsb.s.s Enrvd m rct np,]li.ablc ro lhis rtuj.lt.
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