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DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrcby .fir,n und.r pcnohy of,'crrury lhal I u cxcmpr frcm rhc Conxacloa Lic6r. tiw fo.0E following Essn (Se.?011.5
<br />Busine* and Pmf.$ion Codc)r Any Cny or Co! y ehi.h cauieq n Fnni to .onslruct. !hd. imprcw. dcmlirh or Eplir any
<br />sirudm, Iriu ro ic irs!G., dso EquiRs dE spplk6r for ch Fmir h nb a siEncd srdcmnr rhrr h. or shc is liNn*d pursul
<br />to tne Fovisions of rlE Conrodor'i Lk€nrd llw (Chaptd 9. Colmfi.8 wirh Scctioo 7000 of Divisbn 3 of llll ausincas a.d
<br />Ptlfesions Codc) or rhll lE or she i! .rcmfl rhircfrcm and rhc bdrir tor lhc ,lLg.d crcmplion. Any viohtun of S<lion 7031 5 by lny
<br />omliont for r pemir suhjdr rlE {pplicant to d .ivil p.oaly oi ml mrc lhM fivc hundEd dollnG (1t00).
<br />-,.
<br />!s o*nsr oflhc prctEnr, or m, cmploy&s *irh *ascs os rhcn $b @nlEnerion, will do 0E wod ad d. slrElm t mr
<br />i.rcared 6, o{t Ed lor eL (S{,7(x4, BNies. ind Profcasiom Codd Th. C.nrBlols Liccns L.s des @i a}ply ro M ow. or
<br />rhc rNFny stnt illr u lqhs o*@tr rnd *lb d*s *h m* hituclror tFEtror lnmu8h hn or hcr o*n cnplor*r.
<br />providcd thoi such in:r,mwm.ts m ml inrcD(tr mo,tcrcd aorsh.It lF*6, rlr hilding 6r arp@md L\ $ld wilhin om }tr
<br />of.onpktion, $c Osncr BuiBcr wil haw tlE burdcn of povinS lhd lr or sh. dn d hoiu or in!ftG 0t l,opcn, lor rhc Ftrpos or
<br />}YQBtrEE QMTEXSAIIII!
<br />DEIIAAA.IION
<br />I hcrcby rliirm und.r p.nnlryof ncrjuryonc ollh. followir8 dcchx n,ns:
<br />-lhlvc.
<br />will @inllh a Ccnifrsrcofcon* lo Serlnsurc for workcN .onwB{ion, a,mvtcd for by Selio. l?00 of 1l*
<br />llbd Cod.. fo. ihc ldfomm of lnc wort for whtn lfi. Ffrn ii issucd.
<br />*havc and will mainlaitr wortc.s corycnsll ion in\lramc. us Nquitd by Sccr ion lTuJ of rhc Ljbor Codc. lbt lnc llaformre oI
<br />Frmii is i\$!rl My workcr( c{,mpeosrr ion inrurd..c .rnicr drn lbky nu htrrc:
<br />C
<br />-l
<br />ccn ily rlur in rhc pcrfirmnce .l rhc work t, which rhn Frnir ic issucd. I shall ml cmrloy lny perstr in $y 6ann6
<br />$ as ro h.$m suhjet r. Ihc wo!kc^' .omp.nsdior hws of C.liforni!. lnd rgN rhor af I sh.nld bc.ore .ubjccl Io rhc
<br />wo*c6' con cnsarion pmvkions .t Sdion 370rofrhc LalDr Codc.l shau. fonh*irl $nllly wnh lhos Pmvi\ions
<br />WARNINC: Fnillrc ro scurd worlr( .a,nDcisdnD .ovd.r!c cmnloycr t, dninrl FcMhtui nnd !
<br />horilnd dollfir (Sl(tdx))ion, donnac\ rs thlid.d r{r rhc
<br />inl@$ and allo@y s rcs
<br />Leppu-t-
<br />I hcEby.fftrm und.r pcnolly of pcrjlry lhal I Bn li. sd tndcr pbvision of Chaprs 9 (o@ncing with Sdion ?00O) of Dilision l
<br />of rhe Buri*$ ed P@f.srions Codr, &n Ey liccre is in tull foft !n cfiel.
<br />/s
<br />I hcrbyrlii nu .r Fn.lryof p.rjurylh thcrc h(conslruclhn lcnd
<br />is\ucd (Sc. :ll)97,Civ. C ).
<br />agcn y {in lhc pc.lorlimc .f thc work for qhich lhis Fm[ rs
<br />ATIL]I]INLI)}:CIAIAIIA!
<br />I trrchyafi tDUnrlcr pcnallyol Nrjury onc otlhc folkiwin-q dcclararn,ns:
<br />Drm,lirn,n Pcrmi( Arb.no\ Norifi.rrn,n Fcd.rul Rctul i,,n\ (Tirlc 40, Pd6)
<br />R.quncd hrr$of Nolifi(.ri(nr
<br />-l
<br />ccniiylhd lhc fcdcr0l rc gulal ions rcs.rdin8 asbcsros rcnv,tolarc nol lPpli.lbl. ro rhis lojccr
<br />\rfccniryrur iotr iscotrccl lnsreroconDl!wilhdllCilyttrdCoutrr!
<br />rhovc nEnriomd lrop.rly for ins
<br />Amlicatrl or Agc SiBnoiurc
<br />riz. rcF.snlalircs of lhis Cily ad !
<br />e
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Compressor
<br />Misc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />Smoke Detectors lnstalled
<br />Rouqh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Range
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Fire Damper
<br />Openinos
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rouqh Mech.
<br />Final Test 1
<br />FINAL *rl-lK v.w)0
<br />Notes, Remarks, Etc
<br />MECHANICAL.INSPECTOR RECORD
<br />APPHOVALS
<br />Furnace
<br />lnsulation
<br />Grease Duct
<br />Meter Release
<br />l.r\oamrolrhupnT.ny,rn,.krlusirclr.o r.rnrgwirhlic..\cd.otrtd.ttr\n)con(ru.rrl*rnrj.d(Scr 70l.1, Bu{lm!\
<br />rNl Pn,Ls\i)nCodc lhc Cortrn.roas Li.ctrsc l.!w doc\ trol rfrlyk, $.$ncr olF,p.ny*ho hui[]\ or imtrovc\ rhclcoo.
<br />3nd sho .an rac(,n.\o.h pd.tc.r\ uirh r Contd.n, liccn*, pui(urtrr rorh.Conalcl.ir l-i.cnc Uq)
<br />-l
<br />irrx.trrfl rndrr S.clnr .B &PC lnrrhisicni .
<br />Lcid.r! Addr.s:
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