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MECHANICAL.INSPECTOR RECORD <br />OWNER BIIILDER DELCARATION <br />I h.nby ,fftrn undc, Fnally of pcrjury thrr I @ cxcn'fl hon lhc Co ra.h Liene L3v for rlE aolL* <br />Ausircss lnd Prcfcrsion Code): Atry Cit, or County which rcquircs a Fnil b onsrtu L akd. i'rymvc. d€mlirh or Epdnrny <br />{ruduc, prior ro iri i.sl@c, aho ..quiEs fic ap!,li.a for such Fmir ro lilc a iigmd {lrcmd rhd lE o. lhc n Ie.Ed Inllu.r <br />to thc prcvirions of llE Contradols Lianscn Lai (Chapror 9, Comcncing enh Sc.rion 7000 of Divhio. I of th. B!.imss aild <br />Pmlcirions Codc) or lnar he or sh. k crcnfl thcrctom .nd thc b$h for rhc llhBcd crcqnion. Any violaion of SdIhi 7031 .5 ty rny <br />#ffi ffi;;;ffiffi ffi;ffiffi-ilJ*'*:il, <br />lhc p'oFdy *ho ho rs or in{m6lltur !n *fio dm Mi w* himsclf or hcelf or lhrough hii d h* o*n cnpLyc6. <br />Frcvb.d rhi' su.h inwo8ror3 G mr hrodcn 6r oftrn to, eL, li hosch. rh. building dr itD.owmd h eLt snhin orc lrc& <br />ofconpktb,L r& Osn6 Buil:ld eill hlr ln. hldcn oaprolins rlEr tc or stu dA tur hiu or inpmr fi. poFry iir dE pnqbe or <br />l. *owmrof'h. l,roltit. a cxclusivclyconltuc'nr8 snh li.cnscd c.nt0clor lo onslrucl lhc proj.rt (Scc.7014, Bu\ims <br />d PrDfcxsnn Codc: ThcConrrrcror's l-iccn$ Law docs mr lr'plyroano,ncrotDrupcny*io brilds or ioD.dvcs rh.icon, <br />{id who 6 sds lor such pmirk wirh a Conrndon I lkcned <br />DECIdSAIION <br />I hcEby s,trrm rndcr ,.Mlry of pqjury oft of th. follo{ing dccl&tions: <br />-l <br />hrvc md willmi 0i.aCcnifEarcoiconsnrloScll.ltrsurctorsorkcn comrn\arion,as,'mridcdf.rbys(Iioh.r?(xrolrh. <br />trK- <br />lar rhc |frfo ntrk..c ul lh. $ uA lor whi.h rh: Bnnir n i\nrcd <br />willnrlinhin sorkeri conpen\ari,,n in\tr(lcc, a! requird hy S..ri(1n l?(X) ol rhc t-rhor Crdr. tur rhc,'cnoror0.c ol <br />utri.' rnd |x,li.y u th.r xrc <br />P.licvNutr Er: Etntur <br />_l ..nirr lhd in rh. p.rlor@mc ollh. work lor which lh p.rmir il issucd.l shrll nol cq,loy otry pcmn inanymrnncr <br />s N ro beom slbia' lo lhc wo*e^' con{.nsrion hwr of Califoaria. Md lge fiar if I should bccom rubi(r ro rhe <br />worksl comp.trslion povisions of SRlion 3?00 ol th. t2tnr Codc. I shall. fonhNilh mmply silh rhoc povhions <br />\I RNING Frilur. k, r.ur sfik$r .dmp.n\rrion.olcrrBc i\ <br />.N!l lincc ut ro.n. hundrcd rhnu'rnd dullJis r3l0O,l,tlor, <br />LICINSgI-CltNttdCrc& <br />DECI/N&IION <br />I hsrcby r n n un&r Fnully oi t'crrury lhll I am li.cnBl undcr In vision of Chxprcr 9 (conmncin8 unh Sdrbn 7lrn) ol Dirision 11 <br />ol rhc llu\in$s{nd Pmlcssn'nsCodc. o.d nrylicctrs is i,r tullioNmdcfiai <br />--Lk <br />N N!n$cr: <br />rl)!,ualJqllortENuNcAtillLt <br />I h.rhy ar6.n und.r Folry ol p.rjury rhd rh.rc ir r.o.sfl.tbn lcndin8 aScncy ior lhr I,. {ormncc oirhc work for which 'hi Frdil ii <br />h\tcd (Scc 3097, Civ. C ) <br />a-Stuc liu2ti(LABrflox <br />I h.r$y llirnund.r Ntrilr! ol lErtury.nc ol'thc li'll'^\ irE (le.liflri(nr\ <br />Ihmliri,,n l'cnni\ A\hc{o\ N.rilicrri,r Fcdrrrl Rr!ulnrrn,\ rTirlc 10. Pnn6) <br />Rrquircd l-crr( of Norilirnri)n <br />iry rhd rhc fcdftal rcgtrl ionr re8ardi.8 rsb.s.s r..n,v0l m not .t/icublc to thh pmicl. <br />rr rhar I havc rcad rhir aptlta ri{'ndl {rrc rhd rh.nhilc irfoirnrrn ir.oft.r I aEt6losnply wnhlll Cnyand Counry <br />!bo!c mnliorcd p,ol'.ny lor <br />Atplicant or ACcnl Si8nnlurc: <br />APPROVALS DATE ID/SIG.COMMENTS <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 Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openinqs <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release <br />FINAL 1/r'5 lr,,)3 lol <br />Notes, Remarks, Etc. <br />II <br />I <br />.::m;2/y <br />= <br />i€e/1