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MECHANICAL-INSPECTOR RECORD <br />ID/SIG.OWNER BUTLDER DELCARATTON <br />I h@by amm ud6 pdaly ol pajury tt I m d.mpl tw thc Conlra.loB LkaE Lae for th. following l@n (SB l0l L5 <br />BBh6s ald Profeion Codc)i Ary Cily or Coufly which r.quir6 a lEmir lo @nnrud. alt6, inprovc, danotitt or Epotr ;y <br />slructw. Fior lo its iedc.. abo .cqur6 $c aoplkul tor 3o.h Fmn ro fiL a siSxEd sldffil rhd lE or sh. b licmd pumdl <br />ro rh. provisioN oflh. Conrrrclois Licascd lle (Chafld 9. Codnocae wilh Selion 7000 of Divilion I ol$. BGin6 ed <br />Prefsiotu Cod.) or rh.r lE or sh. is d@pr tlld.nomand rh. bas! aor tb..tLgcd ddplioi. An, violdion oasc.:rion ?011.5 by.ny <br />applicet for a pann 3ubjftls th. applicel ro ! civil pruIy ol nol more th& fiv. huidcd doll$! (5500). <br />l. s owdd oflh. Flpdrx or hy mplo}t€ vnh wag6 s tch sl. @mpo!.lion, wiu do llE worl dd $c artudr s @t <br />iito&d or olIa.d lor slc (sc 70a4, BsilB md PmfdioN cod.: Th. corn8dor's Uc.@ t w do6 rot 4ply lo e oms of <br />lnct,oFly wno hoil& or inproBltE@r, tud who d.c luch @rI hiroclf or h@lf or thrclgh hit or hd oM dploycB. <br />Fovid.d Ihd such imFovaffi m ml i,nad.d or o,Iqld 6r e]c lf. hoBM. fi. hliBiis or itfrcloMl i! $Lt wihin m. <br />'@ofconpldiol $c 0$!6 Blildc eil lErc ln. h8hn oaFDviig thd lE or sh. did ml hilt or inFot dt pllp<ry hr fi. purFk of <br />-t. <br />6 ormd olrh. plopqry. m qdEiv.ly .odlDcting *ilt lto*d contraclos lo onetu i lh. prij.d (S(. ?044. BNinB <br />Md hofcsein Cod.: Th. Contmcrols Li€Gns. tiw doB nor epply lo s o!.o of propdy wto b!il& or improvd thd€on, <br />rnd who cortEcls for such pm.i61s wih . Co ndott, lic.n*d p6@t lo th. ConlB<rors LicGN Lt*). <br />-l <br />m.r.mpt undd sdrion-.4, &Pc ao.tnL r6on. <br />D.lq orrd: <br />EO85E8!.CA!I[E8SA]jON <br />DECI,ARATTON <br />I hdclylIfifr uiddFalryof p6julyon ofth.followirSd.clelioBl <br />-l <br />h.vc &d will mainllin a c6rin !l. oac.n6l to s.lilBuc for w*6 omFaaIior. B Fovid.d for by Sclion 1700 o tuh. <br />krDr Codc. for i. psfoma@ ofth. wort for which lnc Fnit i3 i$u.d. <br />I hav.lndwill m.im,invorkds comp.N.lion iGurance 6 rcquir.d by Sdlion 3?00 ollh. t2bor (bdc. for thc p6lirmdce ol <br />Oc @r[ tor $hicn thi! Frmil is is.d. My nFNatioi iBumc. @id el policy .mbcr e: <br />I cd ify rh!! i. rh. pdfom&c. ollnc $ ork which this Fnh is isuc4 I ihall .or @plo, dn, pmon h ey mmq <br />s s ro b..on. subjet ro rhc portd conr€nsaion lr$ olcalilomia. dd lgrc rnd ia l should taohe bjdl ro!h. <br />wolt6'onpsolionpoviriosofS..lionlT00olthcllborCodqlslEll.fonnwnhconplywittlhosprctilio6 <br />wARltlNc: Failuc ro src sort6' comp.Gdio. ov6d8. ie unlawtul. dd $all 3ubjftl d @p!oF lo aiDjnal FEhi6 lnd <br />civil fii6 up ro on hu.dr.d rho@nd dolld (1100,000), in addilion lo lh. cost ofcoopclsalion, d6ags a protid€d for lh. <br />S..rion 1076ofrh.t bor Codc inrd6l ed allofty s ad. <br />o ic) <br />uc8NsE!_qrNr&lclog <br />UECIdAAII(A <br />I hcrcby aflim undq pqalry of !6jury rhlr I an lic.nei udd pmvision of(-haplF I (olnmocins *nh sdbh ?000) ofDirGnrn ll <br />ol nr Busi,'css and ltolssioa Codc. ed my liccdc is in full iu.. dd cnitr <br />r i.dsc.ras <br />"> <br />- LicwNulnher <br />''7olQr"r <br />,"" 4/tu/ta .*,-"-, Q.+a.- &,r +rlia5 <br />CAIIIAJJCITI}N.LIIIINC-AEETCY <br />I n.Eby .rm !.do FBlry oapqjury lhal lho. is a oNldclion kndins asd.y lot lhc pdfotj@c. ol th. work for which lhb lqnil b <br />issu.d (Se. 3097. Ci!. C.). <br />Aft!rcA.{fD[g,AAAIla! <br />I no!&allmuidd pcnalryof Fjury oneoart aollosinE ddl&llions <br />D.moliriof, Pmils-Arbetos Nolificolion F.doal Rqulalions {TnL 40. Pan6) <br />-Rcnuir.t <br />L.n6 of Nori6cario. <br />-l <br />coti& $ar rhc f.d6d 'ccularioB <br />r.a6dins sberos rcmovsl a. nor aprlictblc lo rhb pDj6r <br />--l <br />csrify rha I h.v. rcad rhis aprlicalb. ad sr . rhar $e sbor. infom.lion is corel. I asrd ro codply {ith all ci} a.d (iury <br />ordinm6 md St.t. Laws Elaiing b b{ildins co nrudioi" dd hftby 6dhoriz. r.!r.$rai!e o t this Cily ed Coutrly to dtd uB)n lhc <br />.bov. nmtioftd prcFny tor iNperior <br /> rplicmr or A!ftr si8notur.:a <br />Appliances <br />lvletal 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 1.7- tg J)r{'r o&! <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />Installation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release <br />FINAL tlr- toJ)eSvlzG f) <br />APPROVALS DATE COMMENTS <br />Smoke Detectors lnstalled <br />Notes, Remarks, Etc. <br />a <br />tt <br />T <br />=