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APPROVALS DATE
<br />Appliances
<br />It/etal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />It/isc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Vents
<br />Rou h Ductwork
<br />Smoke Detectors lnstalled
<br />Toilet Room i Clothes Dryer
<br />Residential Ranqe
<br />Other
<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 />'4'q
<br />&1--(Rou h Mech.
<br />Final Test
<br />fiW'Y,,'r.'n\i,W _U,'t ra/,
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<br />12
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<br />owNER llull-D9t I)Fil,cARATr()N
<br />I [rchy Jlirn nndcr rn0lry (n F-rjry rhnl I rm cx.mpr rinn ih. (innra.t)s' LNnt l]'q irtr rhr |olkisirr3 rci\on lsc.70:11.5
<br />Bn\inr\\ trBl ltor'.\\i,r(,xlc): nJ-CiryorCoo l{hi.hrcqnncsnltirnin,.onNnrl-!llc!.i'npovc.dcnn,li\hJtrcpxtrny'
<br />nru.ntrc. |xia ro !r N{rtrcc, rko rcquncs rhc qplicrtrr l.r {Eh t^-rnrir rr filc r \ilitd {d.hc rhtr hcor shc N li.ctr\cd'nursu ,?.
<br />k, rhc I(,vtnn ot !h( Cofi(ttr'r Li.cnsud liw (Chrnrcr'J, CoNncncin! wilh Sc.li(in ?(xI) ol l)iriri .r ofrhc tlu\i r$ rtrd
<br />uflli.rnr ti,r r n rnrir $hlcds rhc rlnlicnnr ni r.ivilpctrrlryofnor nucrh i firc hundrcdd lhis (55(X))
<br />l. {s 6wnfi of rh. FoFny. m ny .n{,loycs *ih wsg.s !s rhcn $b odt)cnrarhn. will do rhc *{rtr arn dE slralw is ml
<br />inlcd.d or ofi.Ed for $lc (S€.7O[4. Blsimss .nd Phfcsions Codc Th. CotrEcrol s LiccM t:s docs .ol apFly to an osncr of
<br />$c p6Fny *ho builds or impmrcs th.Mn. $d wtF dms $ch mi( hinscll o. her.lfor lhmuEh hk or h.t own employsr,
<br />prolidcd thaBuch imrmwEot @ mr hre,icd oroflbrcd ro, eh. lt ho*cM. tlr l{ildin8 or in{mtr issldviminoncF
<br />ofmnFLrio.. rnc OwM BuitLr *iI hlr ltE lMrk{ ofFDvin8 tt r nc or n drd mr hild or ia!,Dk [E poFtry for tlE purp.s of
<br />-1.
<br />r o*nc. of rhc It(p.nr. 6 cx.lurivcl, conrm.rinS wnh li.cncd .onlrEkrF lo oflnrud rh. E6l$ (Scc. 7044. susim$
<br />ail PrDfNion codcr Th. Contmlor's Lic€nsc L3w does ml lpply to an ow&r of tmp.ny wts huilds or imtmrcs thcrcon.
<br />afld pho m.rrmls for such pDirls with a Conr6cro(\) liccnrd |'uxurnl b rhc C.ntrelols Lic.nsc bw).
<br />I hcrcD.r urdcr Scclion . B. & Pc.lorrhisrctsn
<br />WORXTIiS' COMPFNSATIoN
<br />DEIIdMIIq!
<br />I tcrcby afliirn undcr rEnohy ot Dcrj!ry onc of lhc folloqi.s dcclaalionsi
<br />-l
<br />har dd Dill tuinhi. a Cenifrdr. ofconcfl !o S.lt-lnsure 46. Mrkdl conFnglion, !s ptovided fdr b, serion 3700 ofih.
<br />L{btr tuc. for rhc lcrfoMcc of thc rdt tor *hich rhc p6nl ir L$ucal.
<br />_l hlrc &d will @i.t,io wort6 comp€nsatiotr i.sunrcc, !s Equned by Sc.rio. 1700 of rhc l,hor C.d., for lh. pcrfo.nu@ of
<br />lh. Mrt for whkh iht p.rmn is issEd. My vorkc6' mtrqEns{lior i.s!d@ cdhr {t Flky nnmh.r m
<br />_l ceniiyrhar ir rhcFrl'ornrsnccorrhc wdrk tur whichrhis prnni is nsu.d.l sholl not cmlloyanytlcnon insnyntrm,
<br />s dc ro tr.o'R subl..l b rhc m*.r{ ompcnsdiotr ltrws ot Cilifomi!. and asrcc rhar if I shouH h$om subjd lo ttE
<br />worksa d,ollcn€rbn povirions of Scdion l?m oI thc titnr Codc, , shall. fonhwirh omply *nh rh6s povisions..
<br />WARNING: Fdilur. ro snrc ql'kctr oryEnslion .ovcmec is unhstuL and shau subiri M .oployr lo siminrl lf,Mllix and
<br />.ivil n.cs up ro of hundEd rhou$,t dollds ($l0o.m0). in .ddilhn lo lh. coir of c6m0cnqtion, d.mgcs {s pmvid.d for tlrc<;- lz;(
<br />lllrlLI&IIIg!
<br />t-z 381" bg
<br />,,,, og /+/ r P lnno Cn-- s h"cliu-- .ln -
<br />I hcEb, lrtrn uid.r pcndry of ldjury rnar
<br />htuc{ (se. 3097. ci!. c,).
<br />t a conshction lcndirBrscncy lor rhc l.dnrdn.. ofrhc mrk for shth rht rmril is
<br />i r.ELIIANIJI&CL,IBAIDN
<br />I,r{hyaflihnundcr Dcnilrtolp.rjurrotrc oilhc,ollowin8dc.hmriotrs:
<br />D.rmnirhn PcnnirlAsb$ros Norili.rri{nr Fedczl Rc$larion\ (Tirlc J0. Pnn6)
<br />Rcqxtcd lrtrcr or N.rifi 0rlin
<br />lhard,L.cniry rhd rhc hdrtul rc8uhriors Esaftli,rg trsh.slos r.nnval !r nornntli.ablc ro rhi\ !hj.rl.
<br />is cotrccl t oar( ro comply *irh llCn!rnd counry
<br />roprcscnldilcs oflhk Cily Md Counryh c.rcr uB'nrhc
<br />MECHANICAL-INSPECTOR RECORD
<br />I
<br />COMMENTS
<br />Hood
<br />Meter Release
<br />FINAL
<br />Etc.
<br />l\ilicy Numhlr
<br />-
<br />lrptcs
<br />-
<br />Ihcahyrfinn!!Jcrocnnlryofp.'jrrythnrI li.cn$J tr dcrln'lirnrrolChrprdr)(conrnrncingtrilhSccri{nr7UI))olDivi\ n:1
<br />ol rh. Lulms\rnd Pn'icssiors Cod.. dxr y liccr\c i\ h tullf{ftan' crft.r
<br />,mFny fo. iNpeclior pulpo*s
<br />o, Yivt "".,oe/r+f r9
<br />tD/stG.
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