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MECHANICAL-INSPECTOR HECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER OT]II,DF:R DEI-CARATION
<br />I hcrchy rliirm undcr ncnnlry ()I l^-rJury rlrr I r.r.nltlr rron rlE Cod,!.tri Li.ctr{ litr n, !h. bll vin8rcrw,nlsc.70ll5
<br />Br\i'r.$ r Pn,ts\i(,n Cod.) An! Cily o! Qtnrry *hi.h rcqrm\ r Fnnil r .on\lnrcr- ulrc!. impn,vc. dcnrnish or rqlir rny
<br />{fl.ruro. pri(r b irs i$uiflcc, (l() rclut \ ihc lIlpliunr litr {rcl |f,nnit ir ilc r silned \lrrttnr rhrr h.or shc i\ licco{d nunustr
<br />h rhc ,l isi{rx ol ttu C. ta.ttr\ l-i.cnscd L,* lchintr 0. Cf'n rc .in8 *irh Scdit)n ?0(x) o, Dilnn,n .r .l rhc Bu\tu$ lnd
<br />P'of.\\n \ Codc)orrhd Mor shc iscxcrrpl lhc.elio'.lnd rhch\n ntr rhcallclcd cx.nrPrion A tviolnrnofs(rion7(,ll5trrny
<br />imli.nDrtusF..mnsu$jcchih.3lplicn.[.r$ilpctrdryoln.rnrtrclhanlirrhunJfud olld\ 155fi,
<br />-1.
<br />er oqkr of rhe prorf,dy. q my employss *ilh s!8es &s then sk ..mpc6llion, *iI do l,E qstr and llr 3rffiw n ml
<br />i.nd.d o.ofcmd for $lc (56 ?O14. Buri.*s dd Profcssioosqlde: Thc Co r&ror's Uccne Lje do.s nol !Ppl,lo u owrct of
<br />rlE pFlery *tF hl,Uq 6 inpmEc tlE6n..tn who dG st s* hinclf ot h.r*lf or fircugh fiit or htr o*n cnplores.
<br />tmti&d rnor such irymEftms e Dl hlcM.d or off.Ed for eh.ll h.wvcr. rlE ttilding or hp(ft8nr is$ld wnhin orc Fa
<br />ofconl)kxin. rh. Ovnc. Builhr wil naE lhe hrdca of I,D$nB thd lE or sh. did ml tiih or itfmt di. PoFfly lor th. puFos of
<br />-1.
<br />a. oeft, of rhc ImFny. !m crcltsivcly anltul hB $nh [ccncd contrdos lo onsrwt llE Euc<,r (Ss. 704a. Busims
<br />lnd h!6:ssion Codc: Thc C.htrdctor's Licensc Luw dms nol lpFly lo.n ownct ofpoFny who builds or iry,.oer $.@n
<br />lnd who oirtsds aor ruch Eorc.rs wirh a Conn do(i) lieosql puffldl lo llE Coirtulol s Lkxtre trw).
<br />lancx.nDr u.dcrseron .a &PC forlhbElsr.
<br />IIIBtrESS:.COMPjUSAIION
<br />D&CI.Af,AIION
<br />I h.rcby arfirm undcrycnllty of ldjury o.. of rhc following dNlnBtiom:
<br />I h \. rkls,ll,tuirl inrC.nillclrcoiCon\ctrrloSrlrl'trurclitrs.rkcrrconrt4-n\xrion.a\li{JV.dfulbyS.crionlT(Xrollhc
<br />lrh, (i c. i,ih.IBrlnnurcol rhc sork n)rw[i.hrhc p.nniri\ n\hd
<br />J have a.d witl diot!.. eorkcrs coq,cisalion insuraflft, &s rcquiEd by Setion l?00 of ltc kbor Cd.. for tlE I'ctfomftc of
<br />rhc *ork ao, whkh rhis pcmil is isssd My sort6 onF.erion insurMcc caEtr ud ,olic, nunbo 4l
<br />svo{esf Nahonat ln(rV?mn (, t
<br />-+lo0oOtLaaB [at t
<br />-l
<br />c.nify ltul in rhc pcrformrc offic work for whkh lnh pcrmil is Gs!c( I shallno' cmtloy lny l,cBon in a.y nunmr
<br />e &\ to hecom rubjccl lo rhe wortcm compcnsllion hws o{ C.lifomi!. s.d aBrcc lhlr if I should lE o@ snbiEl b llE
<br />sortql conF.erbn t ovisions of Sdion 1700 of lnc Lahor Codc, I rhrll. fonh*ilh .o"{iy wnh rhdr tE rions
<br />WARNING: Failurc ro scuE *r*cR' ompenslion covmse is uila$tuI, ind shx! subjc.l e €ry,loytr ro dininal Fmlli\ lnd
<br />civil liflcs up ro om hundrd rh.!s!nd doll6 (3100.000), in addnion lo th. .o{ of conPcnslio.. dtmlca d ptovidcd for lh.
<br />o*", alr rhc Irhrci)dc. i' crcn ind
<br />^/.^olddFd,g
<br />Dt rt a-B^uoN
<br />Inuruhyrfli' rndcr p.tr.lryotlujuryrhar t !m li..nsd u tr Pn,visidloiChrprcr9l..nuf,n.irg sirhSccrion?of,orDiui\i'n l
<br />o, rh.Ilusinc\\ 3nd PR,fu\\i()is (-odc, itrd trryliccnsc i\ in lirlllar.rarl.fla.r.
<br />l Ll tplS
<br />s _c
<br />coNsrRncrloN I FrtDll!(: acFNc'v
<br />I hcrcby afii n undc, Fmhy of pcdlry lhd rhce is t oiqrBrioi hndilS !8cfty tor lh. lcrfomm or llE hrk lot *hhh lhn llmn t
<br />isued (sd 3097. civ. c.)
<br />AIILICANLDEEUf,ATTON
<br />I lmi6y Jtn'n undcr pttrrlry ofpcrFry.nc orrhc lollowinS dNlnrarions:
<br />Dcnnlirion Pcrnrih'Artf,\ro\ Norinc ion ftdclo| Rcsul ions(Tnt 40, Pd6)
<br />-R.quiEd
<br />lf,trcr of Nolili..thn
<br />I cdify rhlr rhc acdcml rcslLridnr Egd.linB NtEi6 r.nrvrl !rc nor sp0lkabL ro lhn pmj.tl
<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 / Clolhes Dryer
<br />Residential Range
<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 />Rouqh Mech.
<br />Final Test
<br />Meter Release
<br />FINAL l.l5 -la Jdc2JtQ 'q9
<br />Notes, Remarks, Etc
<br />Drt., Orftr:
<br />B
<br />c!q er\dsdJs6=-
<br />L.nd.a3 Addc*r
<br />-
<br />-l
<br />c.niryrh l htv. rcod lhs aptltdt,n rflj rurc rhd th. ahoE inromrlion is.oret.I08re!o cory)ly snh !U Cirya.d Counly
<br />nrJinan.c\snJ Srrr. Lrw(,$]l|'ry rn bu 'ld rnE con{rucri, L srd h.'.by.ulbnr rcPrcscnldilci ofihis Cilysod Couil, t{r c.lcr uFn tlE
<br />!h!. m tr'n.J nmncnyr$ 'n
<br />ennri.-r,,ae"os,cf* agvwyw- *," ?lrilrB
<br />,*,,,,,"","*,,,,,, z_ lwfuqsufu
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