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MECHANICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I h.r.6y {tfum under pcnalry 6f F,iury rhll I m.renu fmd rlE CoordloF Lkens Lrs for rhc followi.S @sn (Se.,oll.5
<br />Blsiness rd Profssion Cod.J: A.y Cily or Counly shhh r.quird a Fmn lo onsltud. ah.i imprcve dcmolhh or tp.n uy.
<br />rrtuctuE, Irior to irs hsu.rcc. !l$ t !!iEs rtc q,plhur for srh Frmir lo filc a si8n.n stsleftot rhll n o. shc h licen*d l,!N.nr
<br />lo lhe prcvision! 6f rlE Clnra.tor's Liccned Lrw (Chrrrcr 9. Conftrcin! wnh Scclion 7m0 ofDivi.ion 3 oflhc Busin$s.nd
<br />Pml'cssions Codc) or th"t h. d slE is crc'n r rhcrcfron Dd lhc b{qis for lhe olhg.d .rmption. Any violntion of Sdbn ?01 I 5 by rny
<br />rnplicail lor a p.mi $biNlr th. .ptlicB ro . civil p€mlry of rcr frrc rhln fivc hhdred dollds ($500).
<br />-1,
<br />as owrcr ollhc pmpcny, or my .q,lo)e* *ilh *{8.s as ficir solc comFns.lion. vill do lhc work lnd tlE smfie ii ml
<br />i.kndcd or oftcEn tor slc (S6,7iX4. Blsincs lnd Profcssiom Codc: Th. Co.'rrrcrols Li.cne L,r ilo.s mr ,pply ro m owNr ol
<br />th€ rmpcny wrb hil.ts or inpmEi ltlmn. .rd wh6 d6 sBh s* haosclf or h.mlf or lhough his m lEr om ctrployss,
<br />t',ovid.d lnd such impmwmnr m ml hrcnd orofr.rd for slc. lL l[rcE llE ttrildiq c inrm(mnl is eld wilhin om yEu
<br />ofcotr{rlclion. tlE ol,Br Buibcr will h3E lhc h{dcn of p,rvi0g rra h. tr shc dn d hild or i,{mE th. plDFiy for ltE ,u{Ds or
<br />_l- as owner of rhc rolcny. !n crcllsi!.ly conrEcrins wnh li..nsd contEcroF lo onsmd rhc Fnjc.r (Scc 7044, Bu\ift*
<br />ud Ellc$bn cid.r Thc co.h.rors Li.cbe L,e doca nor atplr ro nn 6wnd olpDr.dy sho builds or iml'ov.s thcrcon.
<br />uid sho onlmcrst s!.h nmj$ls *irh a conrncro(, ltcnscn plGu.nr ro rnecontncrois Lntn* L!w).
<br />I nndcrfl trndcr Sccr
<br />D.r.' o"r.r_ _woRrorRsiaaMtENa^io- -
<br />IIECI,AEAIIO!
<br />I hcEby affirnr u.dcr lc.olry of pcrjory om of thc lblbwing dekralions:
<br />lrhtr (-,rlc. lnr rh. |trnflin.c.lrhc qork l& \hr[ rh. Nnrir n isNn
<br />rh. *o lnr shichrh'\ nonnir i\ Lstr(l lvly srrlrr\' .onlpchrri{r insurrNc uricr Jnd |x,|i.) du,$rr rc
<br />Sulr, ev,.l
<br />-I
<br />ccnily lhrl i. rh. r.raormne oilh. *ork for whkh lhh r.rnir h hsucd. I sholl nol cmploy.ny p6$fl in lny monrc.
<br />$ !s to b.om sutlf,r ro rhc *o*e*' .oqr.nsarion laws of Colifornh. ond asN Inar if I elhuld lxcoft subjer 16 tlE
<br />mrkc6 odpcniario. pm"isions ot S..rion .1700 ot thc Litnr Codc. I shall r6nhwirh sn ly wirh rho$ pbvhioN..
<br />WARNINC: F0ilurc lo surc worlcB compcnsdion ovcmgc is unlawtuL atrd shil subjcct an mploycr to aidinal Ftunics ud
<br />civil lin.s up lo onc hn.dr.d thousad dolh (Sl00.Q@). ii addlion lo
<br />'hccosl
<br />ofcomFnslion. dlmBcs !s roviicd for rlE
<br />Scction -1076 ol lh. titr. C.dc, inrftn and aftomy s lcs.
<br />I)k: ' ,! -, 4!ptic{nl:
<br />utrNtEutoNrtdcraa
<br />DECIIIEAIION
<br />Ihcrchy!firmu.rnn0lry.tncrilrrrhalIrmlienslundcrnmvisiotrofChonrcr9(ommncinFwirhs(rio.7m))olDivisionl
<br />ol lhc Buriftrsand lnrlssnn$ Odc.ond nry lic.nsc is in hrll fd.. ntr,l efl'L$l.
<br />1o t-7? T 6
<br />coNiirBu.r]Qrl.lNuNti_d1ilxtr
<br />I hcrchy rlfi.n, undcr lrnrlr, olpcrJurvrhrr rh.r i\ a.on\rrcrion lcn'lin8 lscm, nt rh. J).nnnruicc ofrho rork lir $hri Ihrs F_nnir is
<br />i\{,cd (Scc l0c7- Civ. C )
<br />l.rlcrr NiN:
<br />AIEI.ICAIiLDECLA.IAIION
<br />I trnhy lfii.rn ulln.r pcn,hy of n(rjry om ollhc nnL'wnrs dcclnrrliinF
<br />Dctrxnnn Pcnnir!Ash4bs N.ritlcdion FL\tcml RcAxhrir s (1'rlc 40. Pr 6)
<br />Rcquircd lancrol Mnificibn
<br />I.d'fyrlrr rh. tcd$rldguhrtr,is r.lddi'rs r{h{u\ rcnnrd rrc or rltli.rhL t, rhis fmrcr.
<br />1& ccniry rh! I h*r rcat rhis lnrltrri{rn nnd {dc rhar ih. nktvc nrronuri{nr n .orfrr l rtr$ ri, ..mtly s [h rll cfy r rl ('otrtrr],
<br />rhk ornri{nEd p!or^-dy lnr irstccrion purp\c\
<br />pliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Duct Work
<br />Rough Ductwork
<br />Vents
<br />Toilet Room i Clothes Dryer
<br />Residential Ranoe
<br />Other
<br />Hood
<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 />Rough Mech.77r ,{h cr'lerluTk(t
<br />Final Test
<br />Meter Release
<br />FINAL 5r Vr*:-T*.,'ltz|lt-$
<br />Notes, Remarks, Etc.
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />P.ri"yNu,b".@- t'*, q l? 6 /13
<br />Pcrmile nom (pnn0:
<br />l),,rr
<br />5/lp / lb
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