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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 />Rough Ductwork <br />Vents <br />Toilet Room / Clothes D rYer <br />Residential Ranoe <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.t )-"\{h4l <br />Final Test I e-l{Pqu4a4u" )(t{lc"tr>)0,1\L <br />Meter Release 5-l Y v.w1a' <br />FINAL l(tq 14*#{oz) <br />Notes, Remarks, Etc. <br />II <br />I <br />I <br />MECHANICAL-INSPECTOR RECORD <br />OWNER BUILDER DEI,(]ARAIION <br />I hcrcby rrm uodd p.m!'y of pcijury rhar I m ci.npr toh rhc contElof Licc.* Lra lor rh. followiig rc&en (Ss.7011.5 <br />Busircs ud Prclcsk'n Cod€): Any City o! Counry whi.h Eluircs a ,Hnn to onrru.l. rlld, improrc. d.mlih or Epln My <br />srdcturc, prim ro irs h.uMe. d$ RtuiEs rlF +plter lor tNh Fmil ro lih 3 siSmd rr{emnr lh.r lE or sh. n licd*d plrodr <br />lo ihc prcvni.n.6lrlE ConrElotq Liccnsd Llw {Chaprd 9, Coftm.ncing wirh S€.tion 7000.f Divilion I ofllE Busin.ss and <br />Prefcssions Cod.) o. rhrl lr o3lE ir .xcn{,1 lh4rcton a.d E tesii loi rhc allcScn q.nq,lion. Anyviolarionofscthn?011.5 6ycny <br />applic0nl for o Frni rubj(ls lhc pplica.l lo a civil pcnally or mr @r. fid fiv. hundRd .louas 1S500). <br />-1, <br />as owmr ol lh. pmFny. or hy cmploy.cs wi{h wa8.i .q r}&i. sL @mpeNlion, will &, rnc wori a ltrnnrl@ is mt <br />nncBj.n or oticrcd lor elc (S( 70144. Bu.itusi dd Pnac$io6 Cod.: Thc ConrEcror's Ltcnrc tiq do6 not <br />'l)ply <br />ro an o*M ol <br />lhc rmDcny wtF hilds or inq,mws llEltr. ard qho dc iwh rort( hidslf or hcBclf or lhNush his ot ho own.oploycc*, <br />providcd rhsl su.h inllN\iftna e @l inrcdd, ooficEn tor e]e. U. h.scw. r]E hoildiig or in{,ftrnt is sld wilnii oire Fnr <br />ot onq,lcliotr. lhc Ovrcr Builds will tErc tlr burd.. ol povinS lhn t! or nrc dn d hild or i,ryrcw lhc propsry for thc l)lqne of <br />-1. <br />asowmr.f th. pmpcny. omcrctusirlyco mclin8 wiln lis.sd conlncloN to snslrucr llE pmjccl (S\.-.7Or4. Bllincs <br />u,i Enfsrbn Codc: Thc Conrr&roar Liccnsc Lr* des frn lnply ro d ownd 6f or.p.ny who bnilds or imomv.s rlrcrcon. <br />.nd who co rach lor skh tmicts with r Conh.ro(s) licns.d putrua ro rhc Conlrmtols Uccns L!w). <br />I rn,.rcmd mJrr S(i B & P.C rbrrhis rc!\on. <br />TAXf,Ef,S:TQMrIISAIITN <br />DECIAf,AI1ON <br />I hercby atii.nr undcr penaltyolpsjuryorc ollhc lofi,wins deltralions <br />-lhive{lwilltuinruinsCcnirratofcon$.lroScltlnsloforeortc.or{Etrsdion.rsr,tuvidcnrorbySalion3?mof$cLlbor C!d.. ibr lhc pcrfl)lmne ot rnc *ork fn whicl rlc Fnnil is i$ued. <br />_l hav. ond will minrain workcs conp.ns0lion iNur0Nc. dr rcquircd t y Selion 1700 oI lhe ljbor Codc, for lhe !qlo.@cc ol <br />6c sort ao. whth rhls Fmi is issucd. My work6 oftp.nsdion insurmc. cmtr 0,i Flicy numb.r m: <br />I c.nify lhar in rhc Fnb.M.cc ot ln work ftr whi.h rhis p.rmii i{ hiucd. I shall nor .mploy any Fr$n in aoy nonrcr <br />s *lo b..om sb.iccr lo lhe workds'omFnsolion l.w3 ofC.lifomi4 md l8m thol ifl should b..om sll,Fr lo lhc <br />workal ompcns.lion pmvisions olsdion lr00 of thc t bor tua I shtrll. fonhwnh cotrlrly wiltl lhos pDsirions.. <br />WARNINC F,ilurc ro $.ur. wortcr( c$,npcns0riotr cov.rn8c is unlrwrul. ond shrll sub.jccr on cryloycr to ni.riml Fmht\ lnd <br />ro om hundrcd rho!$nd dollm (Sl(x),lxx)). ih dddirion ro 'h..osl of conlEnsrnrn. dtrroEes !r lmvid.d for lhc <br />SNrion:1076 nrrh.I rlry C.n. inr.m(xtr.lrr <br />/1,-l4 -rf <br />lJof 4e",* q <br />IIECI,ABAIIIIN <br />I h.rchy rfltnr undcr pcnrlryofpcrjrrt thar I !m liccns.{t !ndcr polision ol Chaprcr 9lcontuncin! wirh Sc.riotr 7lXJ0) ofDivisi,,n l <br />ot lhc au\incsr ind Pmtcsionr Codc- lnd nrr liccnsc i( in rull lbrc! lud,ll;er <br />c o <br />goNEIAgCIIANI[Nl2lNClr XrI <br />Ihcrcbyarfiirnudslxnrllyofpcrjurylhllrh.rcGa.otr(ru.rbnlcndir8iscncyfitrrhct^-nnrmMccofrhcsorkrorwhi.hrhis!dnririi <br />is od (Sc.. lr)9r. Civ C ). <br />AITUIANfDICIJBAIION <br />I hcR$y riinn uMrr pcnalry orFrjury.m orrhc nnk'wi'rr dc.lffirion\ <br />Do r,liriun Pcrmir\ ?\tb.d.\ Norili.rrn r ftd.rrl Rctulii(,n\ (Tn[ {. Pd6r <br />-Rcqutcd <br />LclicrolNorilic i)n <br />-l <br />ccnify lhlr ihc lcdcrl Eglhlions rc$rning ash.nos rcnnvrl ec nor arpliclblc to rnis pmtrr. <br />Iccnifyrhu Ih.v.rc thhaptlicario. d sr0rc rh8! th. rtbvc irlorturion is corccr I i8R lo .onDly wnh a Cnyand Cornr, <br />ordinlnccs,nd Srorc Llss rchrins ro buildan8.onslrucrion. rln h.rcby rurh,d2c rclecnl.ri\ri ofrhis Ciiy a.d Counryto cmd u,rn trE <br />lhovc mcnrio.cd tmleny lor q-lt <br />Other <br />Hood <br />/) <br />')\ <br />a {a a- <br />- <br />Lendcr! Addicsr <br />- <br />I <br />= <br />I