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MECHANICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BI'ILDER DELCARATION <br />I lErchy arrm lndcr pcndr, of pdjury rhd I M excnu 6om thc Contr&roB Lt!!e t e for lhc lollowin8 @$n (S..701t.5 <br />Ausancsr ad Aotcssion Cod.): Ary Cary or Colnty which rcquicr . !.rnl to or(ru.l ,ns. inpmvc. tLmli\n or qEn m, <br />rudle, rior ro irs i!.ure, .1$ Equift. lhc .pplicdr lor tkh F ni ro nE 0 siE@d $rcrnr lhlt ll or shc k lic.nEd l,uNanl <br />ro rh. F)virioor of dr Conrebds Li.cn*d &w {Ch.prer 9. Conmfting wirh Se.tioo 7m0 .r oivision I of lh. aNincss and <br />PoL$ions Codc) or lnd lE or slE is cxcdfl lh.rcfon and llp barir lor ln. alk8cn cxctr'plion. Any viohlion of S(lior 701I t by my <br />dtt,licair lor apcimir subjsck rhc lpplica ro acililFmlryolnor mrcrhan five hundcd doUas (5500), <br />-1, <br />as owncr of lhc pmFny, or my emllolrcs wilh wases os lhcn $E compcnslion. will do thc sort and dE {rltr@ i.s Dr <br />intcfrt d o, ofiercd fo, ek (S6.7(X4. Buiimri and Prof.$ions Coder lhc ContElor'3 Lkc.ic tiw doca nol +Ilt to atr owEr of <br />'hcrmtdly <br />whol lds m inpmts tlEmn. !d *ho dG sh md( himsclf or h€Bclf or lhrclsh his or hd op..tplor!c!. <br />pmvid.d rhi 3uh inprom s ft mt inr.id n oiftEn ror $L ll hov.Er. rhc h{ihin8 or inpmwmnl is sh *i&in orc FU <br />olo.IJLri,r! rlE Oqft. &ildd qill haw rtE ttrd.n of!ftvn8 lh.r lt or slE di! hl hiiH or iqmw lhe l,bpory lor tlE purloE of <br />-1. <br />asoBncrofrhe pnpcnr- anciclurirlrco.rracrins $irt liccnsd conrrucroF ro co.no.r rh. roirr (se 7044, aus0rcss <br />and P$rl\iir. Cl'J.: Th. Contldoa3 Lic.nsc kv doc* mr nttly b an ow..r ofir.Fcrlywho buildr or imlmts rhcrco.. <br />&d wno .ontMri aor sucn FoicLJ! *irh ! CoorBdrn(9 licefl$d plrsuaoi ro rhc Contktr\ Liccn* tjw). <br />-l <br />anex.n u dcr Seroo- B. & P.C, lbrftn Eoson <br />III8trE8S:CAMMTAIITS <br />DEq,AAATON <br />I h.rc6y olitrm under Fn lly of!.riu.y om ofllE fouowir8 delanlbm: <br />-l <br />hnw 8n will mintain . Ccnifrlt. or Conscnr ro S.lf-lnw for wortcn omFnsdion. &s rrcvidcn for by 56 on l70O of Ih. <br />L!b.. Cod.. td Ue F.fo.rlEre of ihc w6rt fu vhich rh. Fmit ii ,ssEd. <br />-l <br />hfllc lnd will m.inlain worlcs comp.osll ion iNurarcc. os rcquncd by Sd ion 17{x) ol rhc Llbor C.dc. for rh. F.tomnc. ol <br />rhc *ork forvfiichlhispcm is nsrcd My sorkcr' cohpenetion inslre.c cdicr a r p.ky nunb.r d.: <br />Poli.yN!hh.r:Jrpirc! <br />WARNINC: tuib,. ro surc work r' d,ml.nsrkrn mvcRsc is !nlusa!|. ind shuu suhF.r e .nrtloFr ro sininal tEMlras and <br />civil lnrrs up lo orc hundrcd rhoo\]nd ,lollrn (!l(I].llX)), in i.n, damgcs $ prcvidcd for thc <br />Co{lc. inr.rtn rftIrrttrnoy s <br />I hcE$y atfirm lndcr pcnally of p.rjury thol I an li.cns'd lndcr pmvnion ofchq,ls 9 comftncing {nr! Srrion Ttxr) ofDivisn,n l <br />ol rh. B!\incs$nd Pr.fcsnrE G'dc. dd my li.ctr* k in full fom drl .fi.r*f"*"qffij--)s tc <br />,**ffi :*r .oc *o'* ror *hth,his r'mit .sI h.rcby afrrm undcr Fialry of p.rruy rh,l <br />iislcd (Scc.3097, Civ. C.), <br />APPLICANLDESAAA.IIAN <br />l)ErhyrlImrndrp.nrlryof p.rjuryotrcoarhcf.lkrwin8dc.l arions: <br />Dcnmlilion Pc nils'AsiEslos Nolilicntior ltd.ral Rc8uht bns Onlc &.I'rn(, <br />-Rcqutcd <br />l.rrcr ol Norifurtn' <br />-l <br />ccnily lhlr rhc fedcdl lclrllariom Egndin! 4bcsro\ rm)vd @ nor oprliclbL b rhis lrcjc.l <br />-l <br />ccnily thar I havc rcad tnis .pplkurion sd srorc rlut thc lbor informrion is cotrEt. I as@ ro ompl, wnh .ll Ciry and Cou.ty <br />ofttin!tuc\ anri Srrrc Lf,ws rldirg ro rc,rc{nrarivcs of rhis Cily !trd Counly lo cild llnn t* <br />,how ftn'irmd ptup.ny lor 4aelttlt <br />Appliances <br />Metal Fire Place <br />Ev aporative Cooler <br />Furnace <br />Compressor <br />lt/isc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation A <br />Smoke Detectors lnstalled { <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Range <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 <br />Above T-Bar <br />Rough Mech. <br />Final Tesl <br />Meter Release /) <br />FINAL o -ls-r ww'tL <br />Notes, Remarks, Etc. <br />Ownerl <br />-l.cnifr <br />rhd in rh. nqformrc of rlE work for whi.h lhas l,crmi is i\iu.d. I shlllnor cnploy.nyF $n i. any lMrcr <br />s a lo b.c.m 3ubirl ro thc wo*c onpensalion hws ofc.lilomb. &d rBB lh.l if , slDuld baom sotj.rl lo tll <br />woltdr onwnslnn provl\iohs ol Seli.n 3100 of th. ltbor C.dc I stull. fonhwilh coryrly wilh lho* pDviiiotrr.. <br />--------r------ <br />I <br />I <br />=