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MECHANICAL-INSPECTOR RECORD <br />OWNER BTJILDER DELCARAIION <br />I hcrchy a,firm unds Foalry of rcrjury rhal I d cxcdpr liom rh. C.flractos Liensc lle lor fic following rcMn (S@.?031.t <br />BGi.c$ ald Poacsiion Codc)r Any Ciry or Counr, whi.h Eqlics . tEnn lo co.sh.r. !ltd, iq,ow. d.mlish or qtrn .ny <br />srrud@. prkr lo irs isu.@, ab. equircs rh. +plkoi lor rNh Fmir ro fik r si8md rrll.m $!r lE or shc k lk.n*d pueal <br />ro lh. pidvkbns or tlE Cootracior. Lienscd hw (Ch4rcr 9, Comncing wirh Seclio. ?000 of Divhion 3 ofthc Bosincss and <br />Ptufcssions Cod.) or rhlt n or shc is cr.mpr thcrfrcn.nd thc ha\is for rlE allc8cd cxcrrrio.. An, viobrio. of Serion 70J 1.5 by rny <br />,!tli.! for ! Dermit iubjets rlE arl,lkanl ro a.iril rcn.lr,o[nor mEtho,iv. hundrcd doll"rs (S50o). <br />-1.!s <br />owncr ofltf, prlpcny. or y emrlorRs wilh wtr8cs at fi.n slc ompcnslion. *ill&'llEwort dd llE srttN ir Nr <br />inrcd.d o, oficed for ek (S€.7O14. BuriN$ md Eofc$io.s Codc TIE C.nna.rol. Licc.sc L* .Lcs nol a$ly to on owrcr of <br />lhc ImIEny *hot lds or inpmB llEmn, !d wts d(Bsuchwlt hinsclfor hcmlfor lhml8h hn or hcro*ncmphyt*. <br />prcvidd 6d $ch i,'provw.tss mr iilcB,.t notu for elc. !r. noeM. tE t{ildingo. irFoEm G$ld*LhiroRFe <br />of @rqrhioo. tlt Owncr BuiEo will hav. th hrdcn ol tmving thll hc or rhc dd mr build o inpmve rhe I'mFny lor rh. |)urlns of <br />_1, !s.wncr of rhc topenr. .m.x.lNircly conr&ring wirh liccnrd .onrkro6 ro consDcl rh. lmj(l (se. 7044, BNincs <br />ad EofRsih Cod.: Thc Conhcrols Liccnsc Lr* dcs mr rmly to.nown.r ofImF.ny*ho huilds or iot'oKs rh.ro.. <br />rnd *ho cobrBck for ruch Fmi*h with ! C.n'rdcbrl9 lkcnsd ln6unl ro rhu ConlB ols Lkcnsc L,w). <br />I urcrcnrpr uMcr Sccr <br />}OBtrEB{..CI}!4IENIAIIAN <br />DECLTSAIIIA <br />I lEeby afirn ond6 D.ndy of Frjury oe of rn€ follovine &ilarathtrl <br />Ihavcrdsilli!i' r$nCcniil.JrcolCo srirbSrllli\ur.nr$orkr^'.on!f,n\rri()n,i. {rov edlorhrSccrt,n.l?(x}ofrhc <br />trhor C{nid. l,n rh( r^-rlan u{cofrh.work lnr *hich rhc |xnnir i\ isucrt <br />-l hsvc !tui will 'n.intri. workcB coryEnsark n insura'Ec. as rEqui,rd by Sslion 3700 of lhc knor Codc. for rh. Ffo'rMc of <br />lh. work for which lhh pcmil is iss.d. My *ortqs' c.mrcnsatio. insurancc cutrtr 8rn Plicy nunh.r rcl <br />_l.cniryrhar an rhc pcf.mftc olrh. w6rk a.. *hth ihii p.rnir i\ isso.n.I *hall mt.mDloy.ny pcMn in lny mMrc. <br />s ns lo lx{om subid lo ihc workcis onFnsalio. hss of C.titb.nio. and lgN lhal if I 3hrld tEtoe suhirr to rlE <br />woltcs orrp.Nolio. pmvisions ofSetion 3700 of lhc tibo. Codc.I nEll. aontwi$ otr'ply *ith rho*l)mvhio.s.. <br />WARNINC flilurc lo slE oorkcn .onrr.n\alion colcmAc n lnh*lal on<l \h,ll \ubj.{r an cmployci lo ciminal lrmllis and <br />cilil fincs ur lo onc hundrcd lhousand dollan loo,ftX)), itr 0ddiioi to rhc cosr ol.odD.nidio.. datugc! us l,rovid.d for rh. <br />Seclion 30?6 of lhc Lrbor Codc. inl.rcsl $d <br />DrlLllttra\ <br />ol rlr h^inr\\ ud ltolts\i,r^ Cotlc. r d trrr liron\. n i', lull nm. klofic.r <br />E -C>Jc 3 <br />I h.rchy affi flnundcr lcMltyof !.rjurytis cd (sa 1097, Civ. C.). <br />n(rucrion kndinsarc*yforrhcpdtortuo.corthcw rkntrehi.hrhisllrmit i( <br />I ediryrhd rh. fcd.rnlr.eularions nearding,strros rcmldlarc M {plictrblcro lhhlmjNr <br />ilv I Mlc rcad rhh omlicar ion arxl srutc rha, rhc ahovc infomrnnr i\ concr I asre h .omply sirh rll Cny rtrd Counry <br />Sr0r.t $ rcbti'r8 to buihinS conslrucrio..ond hcEbyaurhnze rc,rc*nuilcs ofr Cny and Counry lo enrr upon $c <br />APPROVALS DATE ID/SIG.COMMENTS <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Fire Damper <br />Openings <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech.4l?2ltSfi 6) <br />Final Test ul <br />Meter Release tl <br />FINAL hlnilk A/hrrk kr' <br />Notes, Remarks, Etc.I <br />/^, tfi=/tt' <br />Grease Duct <br />lnstallation <br />?..-,"".i/tt-r/ rt' <br />l-cnd.rr Addrcs\ <br />,tPU r.rr rVr rXr:t ,l n,rrrrW <br />I ka$y,itnnr u.dm pcn,lly ofp.rjuryotrc olrhc tullowinS dcclanrions: <br />Drmolil n PcrnrillAsbcnos Notiri(.rion FcdcrrlRcEularions(l'itlc J0. Pani) <br />_Rcquircd L.rrcrolNorifr t,n