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MECHANICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER DELC]ARATION
<br />I hcEhy afirm undcr pcnahy ot p.rjlry rhd I m.xcmfl abm fic ContacroN' Lic.Le L3w for lhc follo{ins rasn (S.c.7011.5
<br />Busin.$ a.d Protcsiion Codc)r Ary City or Counly which r.qutcs s rEmit lo clns!rucl. dlr*, imthvc, .hmli*h or rcIEn my
<br />srdclur, lri,I to ns Lssuatuc. also reqrtcs rhc applkdr fi,r s!.h Itml b iL a si8n.d sld.mnl llul lE or sh. is liccnsed |,!rMnr
<br />lo lh. pmvisions of r Conlruior'r Lien*d t w (Chr0lcr 9. CommrcinS wilh S.cli6n 7q)0 of Divisio, I of ll* Ausin.ss ond
<br />PDf.ssions Codc) or th.l lE or sh. is €remfl rheElion snd rhc bosir for Oe alhged .rcrlprion. Ary violalion ofscdhn 7011.5 b, an,
<br />applicanr for a lcnnn slbj(lr rlr al4licanr ro acivil Foahyofnn me rhm 6vc nundrcn dollss ($500).
<br />l. $ owNr of rhc prutEnr, or fl1y cmplorrcs wilh woscs as lhcir $lc comrcnsol ion. will d. rhc eolk 8rn
<br />'h.
<br />srtrtuE is nol
<br />inlcndsj or oltcrcd for slc ( Sa 7014. Btriiic$ tnd E rcsrion{ CGL Thc conr,ciot s Ltlnp llw dcs nol aorly ro ro o*nf oa
<br />rh. tmFny *ho boilds or inlmv$ ihcmtr ud *h..les ssh w.n himsclfo, hcr*ltor rknuSh hii or h.r owncopl.rtcs.
<br />p,ovidcd rt r such iqrermnts m mr inrcd.n or otr r.d roi eh. ll howvcr. rbc trildin8 or itrll,mtmfl ir $u *nhin .m ,er
<br />of.oftplc on, lnc O*n.r auintcr Rill hlw thc l,ur&n of povinS lh{ lE or sh€ dn nor buil] o, inpovc rh. pmtEny for lhc lurlf$ of
<br />-1.
<br />&s o*rcr ofrhc Fo,cny. !md.llsiv.lyconracrins *irh lac..icd d,n{hdm ro.onshcr inc lm]ccl (SE. ?044. Bo\ift$
<br />.nd Pisrc\st n Cod.r Th. c.nrmrols Lic.nrc Law d@s.or attly!o ano*mr otr.oFny who hnilds or inpmrcs rhcreon.
<br />lid eho ontmcls for slch porccls sirh s C.nhcb(s) Iie.<d lu6@nr ro rhc c.ntra{rols LLtn* L3w)
<br />-l
<br />amcrcmDl lndcr Sedion-, D. & P C. forthh E$on,
<br />Ilof,KEXstrOltPrNiAMN
<br />DECIdEAIIO!
<br />I l.i,rc$y rrirmundc. pcnally oi pcrjury otrc otlhe iollosins dcclarolions:
<br />-l
<br />harc lrn will nuintain r Cenifi.,rd of Conscnr ro srlalnxlrc nr wo*cN cotrrpctrslhtr. as rmvidcd fo! t y S*rion :l7m o r
<br />'h.tirq a!c. n{ rhc rtrbrrumc, f'\c trql lq w\nh rhc nontrr tr tr.u.d
<br />!4hJ\crnJNill'nJ'nr0 wurl rc'tutcd 6ySdi,n l70O oarhc L:bd codc,lor rh. pcrformnccol
<br />thc w.rl n, whicn$ispcrn l is is$cd. My*ortcll compcnslrnr insurah-c o cr a.d p.ticy numh.. ec:4r{e turb
<br />-lccni!
<br />thrl h thcl]c ornuEcoflficwnrktorwhichrhist'crniri\(sucd.lshollnoic,nPloytrirypcroninanyia.ncr
<br />$ d{ ro bc.onf, subi.d ro rhe wortcB compcnrllion l,ws ofCllifonri!. lnd aBrcc thur i,l should trcom subrc.r lo lhc
<br />MAe^.oqr.nMrionprovisio.solSccrion.l7(x)olth.titorCode.Ishlll.fonhwilhcorplywirhrhos,r.visions
<br />WARNIN(;: Failurc ro $curc wortcB shpctrrotion covcmSc h u
<br />ciril nn.r ub 16 om hundrcd r
<br />S..rio. 1076 ofrhc t.lf,o, Codc.
<br />*,.,74//o
<br />hous,nd doll0is l$llro.(xn). in nddit i. JrnrSc\ rt fn,vldcd 1,, rlr
<br />ucltNsElcoNr&[.1a.8
<br />DECT.dNAIIQN
<br />t hercby iinmundcr ncnrlryol pcrjtry rhd I aD liccnscd undcr !ruvnnni ofChr|,cr 9 (comntncin! sirh Sccri{)n 7(XX)) orll,vni(n, l
<br />ol rh. Bu\ifc\srnd Pn,,c\\ or\Corl.. JRI ry l..nsr i\ in lulltnr.c xnd.iirr
<br />clllsralclloNr[NDlNc-f,aElcr
<br />I hdr.hy ntfirn und.r pc ,hy.tt rjury rhd rhcrc t r consrru.rin hndins lscncy nn lhc perlomn c orrh. wo,k nn shich lhis pcrmir is
<br />issuLn lscc 3l)o7, Ci! C)
<br />drtlrsaNlrlil:td&tll1]ti
<br />lllrchynfinuntlcr pcntrlly olp.riury onc orrhc nrll,,sirs d(13r,rnn,\.
<br />l).nrlirion I,cnri* Alh(n.s NorillcrLotr |ldofulRc8uhrior\ ( lirl. Ll0. Prn6)
<br />Rcrtutrcd txrrcr of Nori,i(ri,in
<br />-l
<br />ccnify rhal thc fedcnl r€8lhrions rcseding ast csros rcrmlal ad nor ,pplicdbk io rhls pml.cr
<br />!.tniryrhrr I hrvd ft.d rhis{tli. iotrr q crharthcrtx c inr'o.nmliotr n corccr I lgN x,..nPly Nilh rll City trnd Coutrly
<br />ontinxnr.! rn,l Srrr.lrNs r.hf g aurlbrirc rc,rc*nralits otlft Cny ald
<br />r|i)r mnrnnrd tmpcnt ntr
<br />Apt li.ad or A8cnl Si8nitu
<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 Ranoe
<br />Other
<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 I
<br />Above T-Bar .{rt o//T o*>1n)
<br />Rouqh Mech.
<br />Final Test
<br />Meter Release
<br />FINAL /n/tz ),,i
<br />Notes, Remarks, Etc. -( -a
<br />I
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