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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER OELO{RAIION
<br />I lrE6y amrn und$ ncmlly or pcrjury lhrl I m etcopl ton tlE Conurclon Liccns ll* lor th. followin3 ca$n ls€(.?031.t
<br />Blsincss snd Profcshn Code): Atr, Cny or Counry whi.h rcquiEs a ,chn to onsrtod. alr6, nrotow. d.mlirh o, EFn ,ny
<br />itructur. ,rir ro its i$uMcc, als rcquiEr lhc ul)r,li.!fl for su.h pcmit lo filc o iigNd sr.rcm rtur lE or rl'E i! liRnqcd pum0nr
<br />lo rlE l,sdsions of ttr Conlra€tols Liensd Liw (ClBplf 9, ComcminS wilh Sccrion ?O0O oa Divhkin I of rtl 8uritus ond
<br />Pbf€ssions CotL) or rhlr lE or slr is .rcnln rhercfiom lnd rfic bcsis for rlE dbged.xcnpthn, A!, ,iohrion of Serbn 70.11.5 by rny
<br />appli.a for a pcmi $bjrrs rhc lppltcafl roacivil!.nalryotnor moE$d fivc hunrtr.d douds ($5Oo)
<br />-1.
<br />$ ow*r ol rh. ,mFny. or ny cqrlotEs wirh wlscs &! rn n st mnpcnsrion, vill do rwttlrdtunflrrrh il,
<br />inrc'ld.d or oflcrcd loi sL (Se.704,1. Busimss and Pmrcsio.s Codc Th. Contm.rols Li..nF Law &es mr afi,ly ro d o$rcr ol
<br />rhc rmrErty {no huilds or imomws IlEen,,.d who dds$ch6 nimselfo, !.Mlt6rihhugh his or h.r owncq,lor@i
<br />prtkl.d rhar \uch irteh@6Ba @t hlcnd o.oflcan for e]e.lt hoscrci llE hoilding or inpmwmnl issUwirhhnn. yw
<br />ofarqrhtirtr dE Owmr Bui!.r wil haE lrr hudsr of pmvin8 rlEr lE or shc dil mr hrld or iI+er dE fllpoly for tlE puqm ol
<br />-1.
<br />!r owmr of rhc ,mFriy. am crclusircly conrEcrins with liccnsd .onrmror !o onsrod rlE rej.d (se. 7044. Burims
<br />n.d Prokssir Codc Thc Conrturol s Liccns. tre docs mr qrplt ro s osncr of DmtEn, qho blilds .r ihpmler rhc.co..
<br />utrd efio onrmcls for slch,mj.tn *irh 3 coirtucro(, licetrsd p!6e lo rhccoorturois Lkcnsc t w).
<br />-l
<br />amcr.nDl !fldcr Scclion- B. & P.C. ror lhis ftaron.
<br />D.le Ovtr€.
<br />l&08888E!qMtE!$rrON
<br />DECIASAIIJ]N
<br />I hcrcby .ffm !.d.. Fnony of Fjury one of thc following &ilmli,nF:
<br />-l
<br />hiw d will minrsin a C.niftrarc ol Cons.r ro S.lf-lnsurc for mrk6a .on{rnglion. a !rcvid.d tor b, Seio. l7m of $c
<br />Llbor C.de, for rhc Frfomftc ol lrE wrt fo. wnih ifu rmi! B iqrucn.
<br />,l hovc and will mi.tcin *orkc6 compcNelion insuruncc, os r.qutcd by Scrion -]700 of rh. lih.r Cldc fo. ii. Flommcc of
<br />lhc wort( for which lnir Fmil is h$cd. My *ort6 o"{*Nation iNum@ caricr dd Flicy .nnbo @l
<br />?-+qq t'20t0
<br />-lccnilyllElinlfi.Fraormnccofthcworkfor*hichrhis!.rnihnrucd.lshallnor.n{,lot,nypn$nin!"rmaincrs, !* lo becod sbier ro rhc wo*6s mn'{Ensiion lnwr of Caliro.nu dd i8E rnal if I stFlld tccor* subjecr ro rh.
<br />*olitor cdnF.$ra6n lD"iiions or Selion J?oo oa lnc tib6. Cod.. I sh,ll, ronhNnn o,nply *ilh lhrs tmvhio.s..
<br />WARNINC: Failurc ro eu. so.kcr'
<br />civil nrc. ut, ro om hunded Uousnd
<br />tu1. md sh0ll suhjar an cmplorcr ro diminal FMhi.! ,nd
<br />ro fic cosr of.onpcns bn. dsmsca ar povid.d for rh.
<br />I
<br />u!:tDit[!-t0i!ra l.roa
<br />IIT(LIEAIIOTi
<br />I lEEby .flirm undcr FMlry of Frj!ry filr t an tienpd lid€r Fovision of Ch{nrq 9 (on@rcing wilh Sciion 7000) of Dirhion 3
<br />of th. Blsircsr sd Pmf.ssions Cod., !r'd oy licmsc is in tull foN ard cllcl.
<br />C'zo qb7 53 L
<br />,.,,trf4Tt
<br />qANS:IB!,IqITqN,IIIDTNCAGENCT
<br />I hcEhy alfrm und.. Fndly of F jor, llEl llEE h a @nsli!.lion tnrline 68crcy fo. &c p..fo@ of lhc krk for *hkh lhi. IEmn i5
<br />hsucd (s6, 1097. cir, c.).
<br />AIIIII6ITDDgLAIAIIQN
<br />I tmhyallinnundcr |xmllyolDcrjury onc ol rhc nnlowitrs dcclirali,n,\
<br />l).'n,lirn,n P.rmit A\f.nos Norifi.rron r.dcrrl Rc8uhrnnN (I irl.l0. P!n6)
<br />-Rcqutcd
<br />l,qrer ol NolifEri{n,
<br />I ccdily rh,r lhNcr.id rhh ion ad nore r hrl rhc drve inlonntion n corccr I r!1ft r. .onlply wilh rll Cily lnd C.unry
<br />.,,Itrl' r.\ rnl \rrrc I.ir\,.lo btrildine connMrion. and h.rcby oulhoriz rcprcscnlalilB oflhir Ciry md Cou.ryro cnrcr ulnn lh.
<br />ah,vc u i0tudFD.nyfu
<br />Apdicunr or A8cnt stnrr ,^J
<br />a
<br />tlzt/ta
<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 />Smoke Detectors lnstalled
<br />Rouqh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Banqe
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />Openinos
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.
<br />Meter Release
<br />FINAL t7l bt0 7n^,/Tyt/4 a42' )
<br />Notes, Remarks, Etc.I UII
<br />lnstallation
<br />Final Test
<br />t flrd'tNcft:
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<br />Lr.d.* AddB:-
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<br />cenify rnd thc fcdcrll rcSxihrion! Ee.rding asb.sios rcrevd m .or rppltablc lo lhis pDj.!l.
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