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MECHANICAL.INSPECTOR RECORD
<br />O[1{ER BTJTLDER DELCARAITON
<br />I lErcby.rtrm unds Fndly of perjury rh8l I @ cn!,6u rhc Conrdos'Lic.ns Llw forrt follo*ing r&$. (S&,?0ll5
<br />ausin.ss and Pmfcssion Codc)r Ary Ciry or Coufly phi.h Eqlircs a lani lo @isrMl 3Xo. iriprovc, &mlilh or Epan My
<br />smdorc. rrtu ro iK issoaE. d$ EquiE! $c atplicafi fo, s.h Fmn ro nh r sigmd {!Iem rha! lE .r dr is Uc.ns.d puruanl
<br />ro rhc prcvki.ns oftE Conllrclols Liccncd lrw (Ctrpl( 9, Conrcncing Nilh Ssction ?00o of Dilision 3 oflhc Blsines and
<br />Pbf.ssiom Cod.) or thar tE or shc h .x.m9l rhcefrco rnd the &sls for rlE alkScd cr.mprion. Anyviohtio.ofsccrionT0:ll.5byany
<br />qrpli.er for a pcdir subjels rlrc .pplk.fl ro a ciyil pcelt, of mr mrc r.n fivc hundEd dollar (5500)
<br />-1.
<br />rt owm, ol rhe lmtEny. o. my cnploti!. wnh wae.s a rhcn $k or{Enrdaoll. wal! d. rh. vdi. ad ttr sinaIE ic mr
<br />inlcndcd tr oltdd ftr sle (Se.?044. Btsimss ed ftof.sioN Codc TrE Clnlmdoas LLI.$ kw docs ml apply to !i owcr of
<br />lrr rspcny ahd t{il& or inp,.6 tltetr dd }ho doc et Elt hinsclf o, hcNlror ihhueh hb o her own cmplorE.s.
<br />!.o!idcd lhsl such imgroEmnls m tut i.lcn&d orotu for slc lt hokrci lh. trildiiB or i,rFo!1ftd h sh snhin nnc rs
<br />ofonpleioi. rlt Oqid BuiU6 will har E burdd oftDving rhlr ir ot shc did mr build o. inpDw 6e pEpefly to. dE pxrpos oa
<br />-1.
<br />6 o*ncr of rhc lrcIdy, an crlu.ively contddinS wirh lk€n*d conrrchn lo eInocr rtE trei$ (Sd. 704!. BuriN*r
<br />{n hofsbn Cod. Thc Contrelols Licc.s L"w dcs mr lpply ro !n owncr of protcny *lE builds or imlorcs rhcr@r.
<br />{nd wh. onlocrl fir *uch pmirrs sirh a C. rcb(O li.n*d plBuhr ro rh. c.nrBdor's La.ns tlw).
<br />I rmcrc,nfr udcr Sccrn)
<br />woR(ERS. C(IMPFrIS{TI(}N
<br />DECI.AMIION
<br />I h.rcby nltrr lhdcr pc..ht of Fijury ooc of thc following ddlearions
<br />,LrcJ'riu'ltru'nrrtr'JLcn'filJrr,C.irrr,Srll ln\urt' ftr rorkc^- .o.rt nsd ir{, r\ f)vd.d ntr hy Ssrio! .1?{x) ol rhc
<br />r :.t{, ..,,r.. r,,h" rirLrr,xkc rr'hr *i r ir sh[h rht F,r I i. ts.1..1
<br />_l holc ond will D0nrlaitr wortcN comFnssrion insuEncc, as Eiutd by Scdion 3700 of lhc L,bor Codc. for lhc Frfo,i@* of
<br />th. $o* for *hich Ihh pcnni( is nnen. My wort6 @mrcnsation insurec .atriq ,nd policy n!6b., e:
<br />9 rn-te f,-< tw ?
<br />776
<br />_l cc.rily Ind in Uc l)crfortu@ orrhc work rtn {hih rhis p.rnl is hsued.I shnll nor cmploy lny pcmn in any nrtrrcr
<br />n' N lo t*com sublcd b lhc wo*cs comFnsal ion hws of Calinxnia, ond agN ltal if I sholld hccotu suhJ.cr ro rh.
<br />workcs omtcnsalionpo sionsofSection 3?00oflhc tjbor Codc.I slDll. fonh$ilfi NmPly {irh rtne pmvhioos
<br />WARNING Fliturc b sure sorkeB' mmp.nssl ion svcmBc h unh*tu! .nd shrll srbj$l d ciplortr ro ciftiel p.M[i.r rd
<br />civ,l fincs ut ro om hundrcn thousand dolhs (Sl addiliotr to lhc co{ ofcotnpcn\ario.. drmgc\ r\ Pi('vidcd for rhc
<br />Sdion 1076 olrhc L,bor
<br />LIICLISAUAN
<br />I hcrctyulfirnunncr pcnslry o I perjury rhrr I a'.lienen utrdcr tnovirion ofChapr.r I (.\,nnkncinB wnh Sdio. ?0ur) olDivisbn 3
<br />oi rhc Ausircs{ Md Prof.s(n,rs Codc.0 nr} hcn\c n in tull tu.c kl.lic,
<br />gAIIAI]CIXTNIEBDINGJOEICI
<br />I t E-by smm und.r FElry of lcrhry rh.r rh.rc is s mnldMlbn hnding ,gcfty for $c Frfomm. ot thc wk for which lhis pcmn ir
<br />issu.d (S.c. 309'r. Civ. C.).
<br />d.tt|.lc NfD[cl^aarlo!
<br />I l.a$y rltinn unJcr ntfrlly o, r{rjry on. olrhu t,ll,,sirs dccl rarnnN
<br />I)r n)lirnD I'cii ir\ Astldo\ Norifi.rh.i lidcml Rctulxrion\ arirh,10. Prn6)
<br />-R.quncd
<br />Ltncrol Norilicdion
<br />-!
<br />c.niayth0t rhc icdcral rcBuhtions Eg!rdi.8 0shc(os rcnbvtrlorc.ol utrplictrhlc lo rhh,,mJc.l
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />It/isc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Bough Ductwork Ir/z/r,h €.rurrzl /rA---
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Ranqe
<br />Other
<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 />Hough Mech.hA/nt lrrnan /d2_-
<br />Meler Release
<br />FINAL u//"//*-&'rztv>t
<br />Notes, Remarks, Etc.
<br />l.dnir, rhar I hrvc rcld rhk dprli.trtion d {6r. rh,r rhc ah,!e infoMion k c.lml.l alr lo ompl, wnh lllCilyand Counl,
<br />Hood
<br />Final Test
<br />/r/zz4o.4*--l--
<br />I .,,i,1'. NJir
<br />bu ildinS condflllion. nnd
<br />ilx& mnrion d pnptny ftr
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