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APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I h.rcby .flion und., pcn.ly of t rjury lhll I m .xcnpl ftom th. Conrados Licc.c tiw fo. rhc a.lloNirg tcNn (5...7031.5 <br />Busincss trnd Pmf6sion Cod.): Any Cit, or Co! y whi.h tcquircs r Frnn io coslru.l. oltd. imprcve &mthh or rcloi dJ <br />imdft, Fi,r b iri i.suMc. d.o Equias th. lrpli.d lor suci p.flln lo 6lc a signsd stolcftil lhar lE or sh. k licn{d pulsiM <br />ro rh! pmvnions ofrlE conrmcrols Lien*d Law (chE rcr 9. cofrnEncing eirh sdion 7000 of Divishn I .ark Blsire$ ird <br />Pbfcsions Codc) or thar lr o, ihc iscx.n{ thcrefrom dd rhc bsh for rtr all$.n cxcmplion. Any iolalion ot ftclbn 7011.5 by &y <br />lmlkafl fo f.rm subj€li rt 0mlicanl lo s civil pcnahy of not mE lnln fivc hondrcd dolles ($500). <br />-1, <br />as owDs oI lhc pmpcny. or my chplotes eirh wascs as rhen $b onlroerioo. wi[ do dE *nk ud tlE srel@ iq nol <br />inrcnd€d or o,Icrcd for slc (Sd.7Ol4. Blsi6s dd Pllfcsriom Cdlc Thc C.nlradols Lk€ns La* docs not qrrly ro 0n own.r oa <br />lhc ,,DFny wb hrilds.r in{mKs l}rmn. lnd who &m Mh w* himsclf oi hcr*lf or llvoud hi$ ot h.r own .mployccs, <br />providcd rhrr slch iopmEEnrsNmr hrcd.doofictrd nn sE.lf, howcvci rlr bxiling or inpmEnEnl ir s,t wnhin om )!.r <br />otcoq,lcrior rlE Owrcr BuiHci qi nawtlEtrdctrofDnyinslhdlrorshcdAei! ild 6r ir!@w rtE PlolEny for rhc puqrs ol <br />-1.a\owturofrhepopcny.amd.lxsivclyco.di.!wnh!.cn({c. <br />ractos lo.on(tucl lhc lmiccl (S(. 7044, Busm$ <br />dnd Bdcrsnn Codc: Thc Conlr.ctr! Liccnsc Law des not apFly ro !n own$ .i prdDcdy who buildr or impmvcs ttqcon. <br />and who corxBts for such rhF* with a ClNdcto(t liened nuNunr lo rhc Conlmclols Li:cfl* L3w) <br />I mEEmDt unds SErion ,B &PC forrhkEren. <br />UOAf,EIS:g)MTEIAIION <br />DECIAIAIIQ! <br />I hcEby a,fird lndcr peMlty of pqiury onc or rhc fouowing deLmrion* <br />-l <br />h!!c ud eill minrain ! Ccnifrdc of CoNfl ro S.ll-ln rc f6 mrt6'@mFnsdion. s lmvided for by S6ion ]70o ol0E <br />Lahor C.dc, for lhc p.rfm. of thc turI for ehkh llt pdmn i\ issued. <br />-l iarcandsill nuinhinso eB .oornensarion inruBmc. ar requied by Seiiotr 3700 of lhc Ldhr Code . for lhe p.rro@. of <br />rfic srk for which thh lcmir is is{cn. My Do dC om!.netion iBure. .nier .nd polky numbcr &: <br />qLll<3 2lr)I <br />_l ccditr rhsr in lhe pcrlortun.c orrhc work ror which rhii ron is ksucd.I shlll mr cqloy atry pcson in.ny@*. <br />s N <br />'o <br />tr.om sublr b rh. *odcs comrcnsdion kws ofc.lifomi.- ond age rhar if I rhould bdom subjNt lo lhc <br />worlcn' Lrmp.n$iio. povhio.s of Sdion 37m of lhc L.bor Cndc. I shlll. lbnhwnh .onpl, *irh rho$ [ovision... <br />.ivil fifts ut ro orc nundrcd lh.lssnd dolhG (1100,m0 tr nddiri,u t, rhc ro{ of .omFn:arn,r. drnr8cs os rrovidcd for rhc <br />Sstion 1076 or ltu tjbor Cdc. iorcrcsr ud <br />UD,CIAAAIII]N <br />I hcrchyrmnn! crpcialryorFrrtrryrhar I rD li.crqlutrd.r pmvision of Chrnlc, 9 (.omnEE-ins wirnskri rom) ol Divi\ir)n -1 <br />.r rhc Bu\in.$ ond ProfcssionsCode. url aryliccn{ h ir tull f{,rccd .fiudr <br />B lo t1.131, <br />./x L *6L <br />caNsrnuElraNl,llDlxti-&clNel <br />I hcrchy.llirnundcrFnrlryolpcrruryrhai rhcrc isr.of\rtucrbn t in!r!.n.yidrhclcrrornnnccoflhc$nrklorshkhrhi\Frnriri\ <br />i\\ucJ (s& :1091.c1v. c ). <br />a.tfucitlfDl:clllBAllt N <br />I trrh, a,tian u cr Nmlry ol trrlry onc ol r hc tullo*inE dccl&' ion\ <br />DctrD!irion Pcrnrirs A!h!sro\ Nori0cxr6. Fcdrrrl RcSohtn,ns ('riiI Jl),I'd6, <br />Rrqukd L.rrcr of Nolilkirior <br />-l <br />cedify $ar UE f€dcr.l Egul"lions ES&ding ash.stos rcmovsl uc ml at l,lt.bk to this prej.yl <br />2ql ccniry rhd I lEvc Ead rhh ird icarionddsllrcrhrrrhc!t !e int,@rio. h.oBcd I .8re ro mir{ly wirh allCnrrndC.unry <br />r!,1 ,ntr.\ I nLsrr.l xtr\Eprc\cnrdivs orrhh Cny md Counryto cnls !!on rh. <br />{bov. Borioftn I,EFrly <br />ADolicam or As.fl Sisnor :olty <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />lvlisc. Equipment <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork <br />Toilet Room / Clothes Dryer <br />Besidential Ranoe <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openinos <br />lnstallation <br />F.D. Drop Test <br />Above T-Bar <br />Rough Mech.1(P(t'e >\616 <br />Final Test <br />Meter Release <br />FINAL 1/ tylv ,b$a <br />Notes, Remarks, Etc. <br />MECHANICAL.INSPECTOB BECORD <br />Duct Work <br />Vents <br />Above Hard Lid <br />Om.r- <br />WARNING aailurc lo surc worlc^ compcnstion d,leruEc n unhwtul, sd stull subitl {n cmplors lo qimitul pctuths dd <br />o"., Yl-anlr" <br />L.ndcas Nm'- <br />kndd r Addcs' <br />-