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MECHANICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNEN BUTLDER DALCANATrcN
<br />I hcEby 0fitrm und.r lEnally oa I'erjury thll I m cxEmpl amm lh. C.nlractoN Li..ns L3s tor lhc followhg n&$n (56.703 L5
<br />Busincs ond Proltssion Con.): Aiy Cny or Cout, shich rcquires ! Ftni lo .on{tu r. alro. intmw. &mlhh or Epon ony
<br />slodlrc. priorro ni isslrfte, lko rcqutcs lh. amlkanr aoi slch !.mir ro frlcr si8n.d st.lcm rntrl hcorsnc h [ccnscd puBlml
<br />to rhc pmvisions of lhc Cotrlnctor's l,iccnscd bq (Cho,rtcr 9. A,mftncins *irh Sccrion 7000 of Divtion 3 ot lh. Busincss md
<br />PDfe$ions Codc) or rhar h. o, shc is dcnl9| th€Enom lnd rhc b,ih for lhc allcg.d derprioo. Ary violadon of Sdhn 701l.J by any
<br />applkdt to, r Fmit suhl*r rh. lppli.an' ro a .ivil p.nilry of not mE ihm 6vc hundmd dollas ($5(x)).
<br />-1.
<br />as oetur or rnc pmtEnn or my cntploltts *nh wlgcs ar rhcir ole .odp.ns{io.. wiu .lo rrf, wtrk 0ri lh. stu.tu k m'
<br />inr.ndcd or o,Icrcd f eL (S*.r0,11. Busin.s od Profcssk'ns Cori.r Th. Con{crols Liccnr tiw dcs ior lpDly t d o*mr of
<br />rhe popeny qho h(rilds or inq()6 rhc@n, atd who docs Mh sori tihs.lf or nc.*lf or rhmuSh hi. or hf own cnploy.cs,
<br />providcd lhor such in{,mrcmnls N ml intcndcd or ofi.Rd for elc. Il hopcv6. thc building or infmEm is sU ,ilhio oft Jas
<br />of.onplcrio( rtE Osn( Buiur *ill harc thc hrd6 ot treing lh{l lE o sh. did rcr ldb or i!{mw dc I'opsry for lhc luqrs of
<br />-1.
<br />&rosrrof rhc,rol)c y. ao cxclusircly q,nteins enh li.cnsd co.r&roF io @nsrrEt rlx prcr.d (S(. ?o41. Bu$ncs
<br />3d h!n:*sir Codc: Thc C.nlBclols Lic.n* Lrw do.s dn +pl, b e owf,cr ofrrclcny who blilds or im,rows thdon,
<br />lnd who ontmrs for slch por.rtr wnh a Conmdo(o liccnEd !!6u.r ro rhc Contt&rort Liccne Law).
<br />-l
<br />an *cmPl lndn S(tiotr-. A. & P.C. tor th* rcr$n
<br />LVOttO.rts, CoMPENSATTON
<br />IECI.ASAIION
<br />I h.rcby aru'n undcr p.nally of Frjury onc of thc follouing dcclaBlions:
<br />-l
<br />navc &rd will mi.tlh s CenifEarc of Consnl ro Sclf-lnsuE fm {or*es omrcnrarion. a Fovid.d for by Sario, 1700 ol lhc
<br />L,bor Cod., fn Oc Frlolrj1mc of lh. so* for whth thc !6mii ir issucd.
<br />_l havc and *ill mainr.in worleB c.mpcnsaraon ansu.@., &c r.{uir.d by Sdion 3l0o of lhc l,hor Cod.. aor llE Pcrfom. of
<br />rh. wort ro, which rhis pcmjr is ksun. My wmlrds sr{xnsiion iosurftc oEicr un F,lky nunb.r re:
<br />PolicyNrf,bdrJxliEr
<br />_l eflify rhll in ihc pcrformm of rhe so* for which lhis pe,6ir is irsu.d. I shrll ml emlloy.ny r.mn in any mnftr
<br />s N to bcom subicd ro llE wo*cs' comlEnsalion hws of Califomi!. .nd lEN lhal if I slFuld bctom iubjer io rlt
<br />workcs' .onp.nsalk,n pro sions of Seln,n l?00 of lhc L{b.r Codc. I $rll. fonhvilh odply wilh rh,s ,evishB..
<br />WARNING: F,ilur. ro *.nrc wo,Ic^ .omFnsalion ovcruBc is unhqtul. and shBll slbj.rl u cnplnltr lo dinirrn Fodri.. dd
<br />civil nn.s up ro oft hundrcd rhousand dollus (Sl 0m). ir lddnion to rhc c.\r otcodp.nsdnrn. damgcs as tovidcd fo. thr
<br />SNrion 1076 ofrhc Libor Codc, inl.rcs &d
<br />DIiCLAB|IION
<br />I hcrhy Jmnnrndrr Ffulryol txrury rhrr I rnr liccn*l riddr pn)vi\i{n ofChnfr$ 9lconmrmirg wirh S..lion 7{xD) ol l)nnnn,.l
<br />o, lhc !l,\irr.\s nl l'roti$i,,.\ Codr. x'nl nrylir.Dsr r\ i'r ltll la'( rxl rfic.i
<br />SNIIAIJ!:IX]NIINIIIIC.IGIXCI
<br />I hcnby nlnrnr undd IxndtyolF.lury thlt lhsc is aconqrudhn hndinS rscmy for rh. ncrlortumc oflhc wort ror *hich rhil pqnft ic
<br />hsucdiS( :1097. Ci!, C ).
<br />AIELICANLDE(IABAIIAN
<br />I rrnib, anm und.r F.axy olp.rrury on. olrhc folk,wnrS dc.larutions:
<br />Dc'relilbnPcnnils-AsbcsrosNoli'i.lrionltdcrrl,ac8ullrions(lnh,t0.Pilra,
<br />Rcqriod tincr of Norifi cotiotr
<br />l.dilirhd rh. r.dcral rcgulrrions E83rdin8 nsbc(os lcrmval arc rnl npllical,h lo rht pmj.cr.
<br />n !fiI\rar. thar rhc &hrt! inlnrmrion ic corNt. I .8rc Io.omplywnh rll Ciryood Coul,
<br />iry consrrucrion.ond hercbyouthoriz rprcEnrariEr ofthn Ciryand Counry k, cnr.r utbn th.-l.drily
<br />rhar I haw rad rhh
<br />ordiMnccs ond Srolc liws
<br />ah,vc mnrioncd pruFny for
<br />,,," st7-Za/o
<br />Appliances
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Duct Work
<br />lnsulation
<br />Rough Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Ranqe
<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 />Bough Mech.I ll'tt tltl @44W ta--.,
<br />Final Test 'l 'Y l,-
<br />Meter Release _t
<br />FINAL '4D,ttroltl 'irlt,zn .to-
<br />Notes, Remarks, Etc.' lt-
<br />Metal Fire Place
<br />Pre-lnsulation
<br />Smoke Detectors lnstalled
<br />Liccnsc cluss:------Liccnsc Nuober:
<br />-
<br />Drlc Conrrr.lor.
<br />azi',,1?'>
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