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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I h.Bby !firn und( !.uhy ot p.dury rhll I er dcnu tmn rhe Cn tudo6 Liclne Liw fdr rlE aoUo*ing rasn ($c.7011.5
<br />Busincss atu Profcrsion Cod.): Any Cily or Counry whi.h rcquig , Frrui ro snerucr. ah6, inpbvc. dcmlhn or Elat a.y
<br />suu.ru,c. prior ro irs issuarce, aho rqlifts rh. al,Flicanr for such Fnnil ro fih o stncn stlrcmnt thar hc or snc is lien$d t)lrunr
<br />lo lhc Folisionr ofdE Co.tr!.lols Lietr$d l:w ((:1u!1..9. C.mftncin8 wilh Serion 70fiJ ol Dirision I ollhc Businc$ ond
<br />Potcssionr Codc) or th{r lE or shc is crcnor rhcrcfmm and rhc bnsk for thc allcScd cr.mprion Any violdionofScdionT0ll.Snydn,
<br />applic! fofu Fmn 3ubj6k lhc ap0lka.r 16,.itilpcnatryofmt mrcrha. fivc hundrcd dollan {t500).
<br />-1,
<br />&s owmr of lhc ,ml*ny. or my .mrloyNs *iln *aEN a, ltht bli .on{Enslhn. will do llE wct ird rlE drrr@ h ml
<br />inlcnLrl or ofrcrcd for elc (Se.?Ol4. Blsinc$ ard ttofcsio.s G'dq thc Conrr.crols UccNe L€s docs ior q,t,ly ro !n o*rer of
<br />lh.Im,Ely $hn buik , tr i,{roE rlEN( &rr wth .kf,! och trit hinrclf o, hcMlr.r ihrcugh his tr h.r own cnploy.cs.
<br />Pbvid.d rhll slcn imt'mErds e ml inrcnd€d or ofercd for slc lt nomE ln noikinS or impmEmnt k $ld vilhin otu Fe
<br />ofcorptlbtr lhc Owmr Buiu.t w h.w ilF buRhnof|[ovir8 rh,l tx6r srE dil mt t ld or in{,ms lhc plltEl} lorlh. porDosof
<br />l) r.
<br />TOBSEES:COMIEIISAIION
<br />DECI4BAIIAN
<br />I baby lmm un&r pcndry ot Fjury oc otrlE tolloeinS .L.l@rioni:
<br />-l
<br />harc ud will mirlli, r C.nifslc of Conenr ro Self-In,uE f sots .ompcns.rion. s Fovi!.d fo] by Sclion 3?00 of$.
<br />tihor @c, lo. lhc p6foi11wc of rh. wo,t fo. shi.h thc lenar h hscd.
<br />_l hrvc and eill nainluifl wortcG comFnsllion insuBrcc, s rcquircd by Salion 1700 of thc Llbor Codc, for lhe p€.romie or
<br />insurun.c ceicr od Flicy numb.r @:
<br />,,:,, lltlt?
<br />-l
<br />ccniirthal in rhcn rlormne ofrhe,or[ for qhi.hlhis pcrmjl is issurd.l shull nol cnploy an, pclso. i.'nynMncr
<br />5 0s
<br />'o
<br />tr.om suh,.rr ro rh. "6.xn( ory,.n{ri.n hws of C.li,omia .hd agrcc rhNr ir I sh.uld tEonr subi.r! ro llE
<br />work ^ .onp.nsdio. pm sions ors..rion lTooolrhc Lnh{ C.d..l ihdu. fonhwirhomply wth lhr pmvnions..
<br />WARNINC: Failurc lo slrc workcc'comr.nsalion colcBBc is unlawful. and shrll suhirl an c,q'lo
<br />civil fines up lo orc fiundrcd ltous.d doll ).i
<br />S..!,{i.ll)76 o, th.l. rrtr (n([. rr.rrn]nlsltt"ltcr--1 1
<br />I n€reby aitm undcr llcnlhy of D.rjury thlt I om lienen provision oachallcr 9(commftin8 eilt Sdion 7000) ofDilisnln l
<br />ol Ih. Burincss m'l Pnnissions Cod.. ard nry li.cn\. ir h fnll fitr.c f cflcd -
<br />ttltr* It<r- -l
<br />I hcrcby lllnmund.r lEn0llyol,rrjury dut lltrrc h ! conslfl.tion
<br />issu.i l S.r. 1097. Civ C.)
<br />u8cmy lor lhc p€raormrna of lbc *ork tor !hi.h rhis ticrmn i\
<br />AflLlqANlDECLrtBAI&N
<br />I tml,y nnnundo lEull, olpcijury o.e ofrhc followine dccloruriotrs:
<br />O.rmlirion PcrnirrAsbr{Ds Norifi.dion Fcd*al Rcgohrion\ (Tirle !l1), Pd6)
<br />-Rcquncd
<br />t.lrcr of Notiicnlion
<br />-l
<br />.cnify lh0t rhc lcd.lrl ESul bns rcB&Jin8 asb.st s Enovrl r. nor Jl)pli.ablc lo this lroirt.
<br />l.cnlry rhnr I hrrr rc lihis rpplicnri,,nand {rrc'harrhcrtD\c inlonmrion k.orcd !uere ro.omply wirh lllCiryond Cou.ty
<br />odinxnccs dd Sratc L€ss rclarifl[ ro b!orrhh Cnrlnd Cornryro c crnl.n'r.
<br />ltx,vc mnrio.cd pm!.ny ti)r
<br />A,rplicinl or A8cnl SiSnaturc:
<br />(.1K
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Mi sc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rouqh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Ranqe
<br />Other
<br />Hood
<br />e I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />enings
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Bough Mech.
<br />Final Test
<br />Meter Release
<br />FINAL {/t,4lk r1fiU.*s,41
<br />Notes, Remarks, Etc
<br />Above T-Bar
<br />L rsosnc,orrhcprop.ny- adcrclu\ilclr.onlrdinE q,ilh lic!tred..nrr!.roFroconntucr rhe poj(l (Scc 701.1,8u\im*
<br />rM lrnli$i'trcodc:ThcConkcrol\Li.ctrscLrwduc\n.laFtlyt,rnoqn$orI'fl)p. ywhobuildsornntrclcsthcrc.n,
<br />nd who Ll,nrEc( rir skh ri+cr\ wirh u 6nim.ro(s) lic.trsd nu^uafr |o rh. Conr!!.t, \ l,kcn$ lj*)
<br />I a'n.xctr'd undcr Sodion_. B &P.C lnr rhi\ rclr)n
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