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MECHANICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCAflATION <br />I hcrcby alfirm utrd( Fndlr, of lerFry th.r I m cx.mfl nrn thc Conracro6 LLIi$ L!* fo. lhc follo*irg lwi (St.70l I t <br />Blsin.s a P.ofcasion Codc): ary Cny or Counly {ni.h tquter a pcmh lo @n.ltul. &ltc, inpmv.. (Lmlhh or q!.t dv' <br />snlcrE. t ior to irs issumc. lko rcquircs lh.,pt het lor su.h Fmil lo lilc a.i8xEd sllrcGnl lh n or sh. ir lkcnscd Iusanl <br />ro $€ prcvisnrns ot rh. c.ntstols Licened Llw (Ch!pte, 9. Co@min8 wilh Scdion ?O0O ol Divtion 3 of fic Aus's$ a.d' <br />Ptufcssions Codc) or lhd hc or slr ir excqi rncEamm and rlE bosis ror Oc ,lLgcd cr.nll,thn. Any violsridnotsc&n ?031.5 bv anv' <br />aDDlicanr lor a lEmll subj.rls rhc aDplicanr h a civil D€nalry or oor mE lhln five hudcd doue. (S5m). I <br />Lr\ o{.crolrhcJ,n)Jrny.or uc rtloyccs rvIhriAcri\ rhcir v)lc .o'nP.n\arnnr. trillio lltr tr.r[]n,lr,tindft ii n-r <br />rhc nmt ny NhohtrLLd\.rrnnnN$thc.d)n,Dd\larJoc\{klrtrlrkhnn\.llorhcr\clrorrhR{!hhi\.rhcrowtrt,nlrl,)vcc\- <br />povi,leJrhrrsurhi'npn{ttnr(rN..n{iJc'klt'l,,niruJlnr!'lcll,ln$ev.trhchuiltliD!ornllPr)rcfnrNv,U*nhinttvttr <br />-1. <br />!s owrcr of rhc lto!.ny, am .x.lusivcly onlreting enh lccd\cd co,fuoE lo onslel rlt lnoj{s (Se. ?044. BrsiB <br />&d Prot sin Cod. 'Ilrc Conrtulois Lic.n* Lle do.e ool .pply lo sn o*nf or pbFny who hilds or inprows ih.6n <br />rd who otrrncis fd.u.h F.iEls wilt! Conltrto(s) ltcned puFU llolhcao relols Li.cn* tjw) <br />I rNcxctrrpr und.r sccin)B &PC lbtrhhtcoson. <br />IlORI(FRSl CONTPFNSATI(IN <br />PECL/Tf,AI&! <br />I hcrcby ofinmundcr pcidy of ocrju.y orc oflhc followine deludri.ns <br />-l <br />hovc dn wil @inhin aCcfiifralcolcoN to Sdf-lmE for mrt6 @npctsrio...3 prtr1ilcd for bvs6riot 37mof ll* <br />t bor Co<le. forrlr tEfru.of lt *ori( for whkh llE Fmil b ilsued- <br />-! h.vc ,nd will @iol,in workEs cotrli \arion i.su6ncc. as equiEd by S€lion l70O 6r llE ljbor tu . lor rh. p.nmc of <br />IE work for which rhh p.mil is issrd. My *ork6 @nFo{ion insuEe @ie, ald polacy numbcr e: <br />WARNIIG: Fdil@ ro surc krt.N' @qEn.arion ovcESc n unb*tuL ad rlEll subj.rl m cq,lotcr lo 6ioin l IEEhL5 lnd <br />c il linB up 16 orc hudEd lholsnd dolls (Sl&.000), in trddition to llE coi ol.onpcNlion. datugct !s povitcd r.r rhc <br />Sccrion 1076 of rh. ljhor Cdc, iirG$ a.d atbrey i fes. <br />UIIX$,TCI)NIBA(IOB <br />D&CLl$ir[a! <br />ol rhc Bn\itus\ rtrd Pnnissi(rNCid.. nl ry lir.i.c is iri lirll lorlT nnd cllicr <br />qollI8lq[aB.LENDELilcESCI <br />I hmby rmrm un&r pcnrhy ofp.rh.y$.1lhdc irr onsltu.lioi hidiig agcmy for ln pdfommc of thc vut for whi.h lhi. Pcmil i! <br />issx.d (scc.109?, Civ C.) <br />L.ndd'3 Add,Es' <br />- <br />AITLIIANLDIICIASAIION <br />I LNby lrIfln u ndcr p. rlr, of trtury om ol rlrc lillo*in! d(hor i(nr( <br />DcnElirioi Pc.nirr^\c\skrs Norifi.trrn,n F.dctul RcBUhrn N fl'ilc.1lr. P!n6) <br />Rcquncd t licrof Norili.lrirr <br />-l <br />enily ttat rh. fcdcrd cgirldions Egsdin8 Nt sros rcm,vtl drc nol apPliclbb l. rhk ln)ir <br />hirc N)niorcn lrorny l(tr i'i\l'crri(rr t[po{s <br />Appli.ant or AB.nt SiSnorurc:- <br />Appliances <br />lvletal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rouoh Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openinqs <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release <br />FINAL zlTl tl ,/-.u(41 ) <br />Notes, Remarks, Etc <br />-l.cniry <br />rhd in rh. pcrlnrmm€ of rhe wort l'or whi.h lhis p$nrir is hsucd, I shdll tror.mPloy lny Fson in nn, mancr <br />$ as io hcrom suhj.d ro rhc *uit.u compcnsdion laws of Colifomi!. md 0gN lhal if I stnold bcco'rc subjcd to llE <br />wo (ns €ompcnern,i rDviliors ofslclion lT0ooflh.litor Codc,l ihall, forlhwiln complr eilh rho$ Provi\ions. <br />,\Dplnrnr: <br />Pcrmircc nom ( Drinr ) <br />fT <br />I <br />i- <br />= <br />T-