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MECHANICAL-INSPECTOR RECORD
<br />OWNER IUILDER DELCARATION
<br />I ncElry o,Irm undn p.naty or Frjury thot I m cxrmpr tum rh. con@ro6 Lienc Lru ror rhc rolbudt!\:!$n (scc.lo3 I 5
<br />Blsinc$ and Pofcrsion Codc): Any Cny or C@nry which EquR! , rEnr ro m.{dd. ells. inpmv.. dctulnh or rcp* uy
<br />3tructurc, prior ro ir hsar., oho rqliEr thc .pplhdnr fo, such Fffii lo nh ! siemd slll.mnt fia,t L or shc i! li.msd puNa
<br />h lnc pmvisions of tlE Conlrslor's LicnEd Llw (Ch!,rlcr 9. Commncing wnh SNlion 70OJ of Division J of lhc Blsincss and
<br />Pmtcssions Co&) or rhar lt or rhc is.rehfl thsriiom dd the busir for lh. !lh!.d .x.trplion. AnyviolationofSNtb.T03l.Sbyany
<br />appliclnt for a ,..nir llbiEls UE applicanl lo r .ivil pcmly ol nol mE lhan fivc hu lrcd dollas (5500).
<br />-1,
<br />ds owr( of rhc popcny. or 6y .nploylci *nh w0gcs rs their $h oqEnstion. *ill & ll* $ftk &d $e ilnrnE i\ mr
<br />intcdcd or oilcrcd for elc (Se.7(M. Ausims &d PtDfcssiom Codo Thc Conr.eroca Licns ljw docs tror srply ro an owrct ol
<br />!h. peFny who hilt\ or nq,oB thc6n. lrxl who d6 Mh wli nin\.lf o, hcrclf or lhtouSh his or tut own ci{Lyccs.
<br />nrovidcd rhsr such nnpmEr.E e tur hrcn lcd or .lIqd fo. sb. lf. hofts. th. ti{ildiry o. iqrwmtn is eB withii dc tlt
<br />ofcomplcrbtr lhc Owrcr Build* will harc 0E h!d.n otFwi.s Er lE 6 shc did mr blild m o'pmrc lnc pmDcly for tlf Plrfn* of
<br />-1.
<br />ds owN,.r rhu ,epqry, o.x.lusiv.ly.ontB.li.8 wnh li.aEd.o ndoBlo oislto.r lhc leirr (Se.7044, Burims
<br />ord hD,tsshn Codc: Ths Coirturof s Lic.nsc Llw d6cs mr otply ro u oencr of prcpcny who builds or imprctcs lhoen.
<br />dnd who 6nrh.k tor such pmirrs wirh a Conrrero(9 lk.Md pullur lo rhe Coolndor'3 Liccn* Llw),
<br />!.n cr.mt undrr sc(rnr
<br />]rcBKEBL!AMPENSAIION
<br />DECI.AMII!]N
<br />, hcrcby rlfirm undcr pc.ahy of pcrjury one ofth. folL$ing dshnlionF:
<br />-l
<br />haw dn will minllin r CcnifEatc oacon$ to S.lf-lnsure for *orkc6 .o.rpc.siioo. 6 povidcd for hy S..lion 3?m of Inc
<br />lr!o. Codc. for 6e pcdoMcc ol UE wolt for whkh llE F.mil is i*ucd.
<br />-l hav. and will mainlsin wortcts srycisarior ins!runcc, 6 rciutcd by SGlion 1700 of 0E Llhor Cod., for llE psfolmne of
<br />rhc worl for ehich rhi Fmrit is is$cd. My wor&d .oqrcnrdion insuee @i.. .rd policy nnnbd @:
<br />cort, - [^1,'8G.3 aq r ? *',^.r. c'rJeS t
<br />L\, s tDo i.. o/fe,
<br />-l
<br />cnitylhat itr rhc FrfornEncc ofrhc wo,k for $hth rhis Frnir h irsucd. I shall mr cmploy ony Pcrstr in lny oanncr
<br />$ 0sro tE o'ft suhtcr ro lhc w ciscom!.nsrionlawsofcaliforni4!trdcsNrharifIsholldh.co@cubj.cltoltE
<br />workm omr.nsorion pmtisionsofSction ITOO oflhc Llhor Codc.I shdl aonhwnh Nnply wirh rhns tmvkions..
<br />WARNING, Faitur. t, {.nrc *r,*.rL $nD.nsdioh covc',!c i\ u.lrRlnl. ond shrll suhF_t an cmploycr kr qihnr Jrtuhi.s rnd
<br />civil fincs up k' otu hutrdrcd rhousd*l d.lles (s|fi),O(x)), in rddniotr ro lhe co( ofcompcnsrrion. datug$ d\ lford.d ir rh.
<br />scrion 1076olth. bhor Cod.._^-^,[^[;%.--f llo
<br />LICDASEDJONISAETOA
<br />IIEIIIBAIION
<br />I hcrchy rfinnundn pcnaxy of rrjury lh.t I am liansd !trdc. rmvhion ofChuprct 9(..mftn.in! wkh sdion luD) olDi{ision l
<br />ot $c ausin.\r ,nd Prurc$ions codc. ld ny lic.ns ir ir lull rorc otl .ifsr
<br />C7-o Llqa2of
<br />t
<br />AIILICANLDECLAM]IA!
<br />I lxr$yarlinnundcr ncnrlry ofp.rjuryonc or rhc n,lhsins dc.hrarn,ns
<br />Dc hliri. Pc nni^sh.ros Norificdion lrcdcralRqultrrions aInh40. Pani)
<br />-Rcquncd
<br />brrcr ol Noli,lcalion
<br />I ccnifyrh,t rfu fcdrJl r.Bulorions Egarding rstEsros rcmval,rc nor amlklhle ro rhn ntoFt
<br />-l
<br />ccnif, that I har rcad rhh apnlitri.n ud (ar. rhal rhc ah,r. informrion is oncd I a8r ro smply
<br />ud Counry ro cnrd ulnn rlrctr{rur(nn,. rn(l h.r.hyrurh.ril. rcJtr$rnrJrrr
<br />APPBOVALS DATE ID/SIG.COMMENTS
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Irlisc. Equipment
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rouqh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Ranoe
<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 />Rough Mech.
<br />Meter Release
<br />FINAL +71-A -lldrtafr /)
<br />Notes, Remarks, Etc.
<br />ei,r,+S*<a_
<br />Duct Work
<br />Other
<br />Above T-Bar
<br />Final Test
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<br />CI)NSTRUCTmN LFNDINC AGIiNCY
<br />IhcrcbyarijrnundcrlcMlryoltcrturyth lhc,c h a onslrucriotr lendins alcnc, nt rhc Prrfr,mn.. ofrhc *ork lbr whichltis Pcrmi n
<br />isucd (Sc..1097. Civ C.).
<br />I cnl '\ Nnn,..
<br />ordinances and Shlc Lrws
<br />ah)vc mnriomd pmpcny hr r/ula
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