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MECHANICAL.INSPECTOR RECOHD <br />APPROVALS DATE ID/SIG.COMMENTS,O$'NEA SUILDER DEI,(IIATION <br />I hcrcby aoim uftlc. IEnaiy or psjury lhd I m.remg lon rhc Contm.bN Lirnc L.w aor the fouowing @$n {Scc.70-11.5 <br />Bwinc$ .nd Prcf.$ion Codc)r Any Cny or C@nry uhth rluis a r{mir ro @nnrucl. all$. irylmvc, dcmolhh or Et[t lnt <br />srruclurc. prior ro its L$utrmc. llso roquiEs rn opplicanr fo. su.h lErmir ro 6L a si8ncn slolcm rhll he or shc ir liensd plls@r <br />ro the Imvishnr of llt Conmdor'3 Lic.n*d Lle (Cnlr,rcr 9. Cdnmring Dit[ Sccrion 7000 of Divisioi 3 of llk Busi$s ed <br />Profesriors Codc]or rhd lEo, shc isqcnpr OcE&onand lh b$h fo. Oc aleg.d.rcr{rioi. Ary violdior of SElbtr 7011.5 b, any <br />,mli.arr fo, r Fmn subj*ri rnc apolicrnl ro 0 civilF.ihyofrcr mE rh3n liv. hu.dEd don6 ($00) <br />-1. <br />ai oaftr oilhc lopcny, or my cmplorres wnh was.s as rncn $b onpcos ion. wiu do the wfft{ r.d ltE slf,Elm b nol <br />inlcdcd or otrer.d ror sl. (Sf.7o44. Businc$ ond Pmf.ssion. Codc: Th€ Conlr.clols Liccnrc tiw d@s nol !p,,ly ro ,n o*tur ol <br />$c neFn, *ho boilds or in+Fhs tlEeii. ard wh6 dGs sh h,l hifrclf or heMlr or rhmu8h his or hcr own cmployccc. <br />pmlu.n iilr such int,ormnN N ml hlcndcd ot ofiqtd for slc. l( hoEE dE bultdhs or inpr.wftnr ir $td wnhin oN Fe <br />of.o,iphiotr rll OqM Builtr *iU haw rlE hrd.n of Foiing rh! lE or sh. dn ml h{ild or ir{mw dE FoFry ftr rlr luqrs ot <br />-l..sopNrofthcImlcny.amcxclusivclyconrrscritrSwiihliccnscdco <br />reroB ro con(tucr rlE rmjccr (56.7044. Burincs <br />.!d hDft$ion Codc: Th. Conkaror\ LiccNc Liw do.\ nor amlyro o.own.. oitmI.rly *ho hlilds or improvcs lheron. <br />and eho ontE.rs tor slch pmrcds $nha Conr@ro(sl liccnsed punla ro rhc Conradoir Liftne Lis) <br />-l <br />omcrcmpr udd Sarhi-, B. & P.C. forrhis Ea$n. <br />wo{l(i rls' coMPnNsal'toN <br />DECI.AIAIION <br />I h.rcb, rlfirnr lndcryc.olly ot psjlry onc of rh€ followin8 dsldd ionsl <br />-l <br />havc ad will minrlin ! CcnifEltr of Conscnr lo S.lf-lnsur. for sorkdl ompcnsrion, &r povilcd for by Sdaon 3700 of rh. <br />Llho Code fm rhc Frfollrec ol Oe *ork fo whth thc p€nn i. irsu.d. <br />-l <br />h0v. snd *ill mDinloi. *orlcB compcnsntion iDsur!rc.. as rcqxircd hy Setion 3700oflhe Labor Codc. for ihc lxrtdmDncc of <br />lhc w.rk for shich Ihi prnnit is isucd Myworkctr .onrp.nstrrion insuramc cnEicr lnd polty nuhb.r uc: <br />tcq <br />5d 1"1 <br />-l <br />ccnilyrhar ia rhc l,crforroncc ofrhc work foi which this pcmn h iarucd. I shall nor cmployaoy p.*on in rny mnmr <br />so $ to tr.o'rc subjccl ro rhc mdcl conpcnsrion l0*s of Calitumi0, nnd o8rcc lhtrt if I sholld h.roft subjer lo rh. <br />worlcrj omp.ns ion povisionsofscclion l?00oflhc tihor Codc.I shall. font*irhohpl,*nh thos pmvi.ioni <br />WAnNINGT Fniturc h su. wortcG conFnsaiion h unbwrul and sh.ll subirl a cmtk,trr lo qinn.al pcBlri:r ud <br />oddht,n to ln cosr olsmFenetiofl- datug€s !s,ftridcd for rhccivil nnrs up to.m hlndrcd lho$and dollus (SI <br />s(! ,rr rrr..rllrr lrlrr (,)rlr.rfur.nInl <br />, 4-t ID.ht a tt <br />LICINIEUJQNINATIX <br />D[CLA[AfIQr{ <br />I hcrcbyrmnnundcr pcnulryol Fcrjury rhar I rm liccnsri udcr pruvi\i.n or Chrpro 9 {mnnftn.ing wir h sc.r tr 7uxl)ofDirhir)n 1 <br />.l rhc Bnsims Md PolisionsCod.. dt trryli.ctrr h ir Iull lar.c d ctltd. <br />o <br />o1 cA <br />A[tttcaNlD[rt BAltlJN <br />I lr(hy3fiinn undcr nrtrrlry ol pcrjurv om.trhc li)llowing dcclur!li{nx: <br />Dcmolirtrnr Prii ir\ \tiqo\ Norin.dio, r.dchl Rcluhn,x (Tir[ 40. Pd6) <br />-R.qutrcd <br />l.rrcr o, Nrrirl.rrittr, <br />-l <br />ccnif, th3t lhc ndcrulrcEulliions Esudnr8 a\h(srosrcnxrlll!rc mr rpplicah[ t,lhi\ proJLtl <br />-, <br />ccrlily thar I h.vc ro|d rhk applicld,n,id slllc lhtrl thc ihrvc infornEtiotr n conccl I oera lo omdy rnh .11 Cny lnd O,unty <br />rdi, n..\rmlsrrrrlrw\,.ildingclnnru.riotr ard hcr.byaurrsrirc rctrcF aliv.s of rhis Ciry".d Counly'o cnrcr u|snln. <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Ivlisc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranoe <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openinos <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />I r. <br />Rouqh Mech.llllrltil,'/) <br />Final Test <br />Meter Release lt. <br />FINAL uilqil t /\ <br />Notes, Remarks, Etc.t <br />Other <br />Above T-Bar <br />/>l&./ <br />D.l.: OwE: <br />/O zLl rrl <br />IQNIiIAIEUUNIENDIIGTTCIiIII <br />I .'.J. ''\ \, tr.' <br />rtxrc n{nrioncd pnipcny itr <br />^"-7LrL3- <br />tt <br />Itt <br />tt