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MECHANICAL.INSPECTOR RECORD
<br />()l!Nt,tR B(r ,t)tR I)t:t,( aR,\ ll(rN
<br />I h.rchy rrtrm und.r pcMlly of pdjury rhd I d.rcnq fmm fi. ConlEclm' LiccM Lrs fo, rlE follo*ing rcr$n (ss.7011.5'
<br />Busin.* !tu Pmfcssion Codc) tuy Cily or County whicn Eauires s pcmir lo connrucl. slls. irymt, d.mliti or Epln 3ny
<br />strucrurc. p or ro irs issuune. aho ctuiEs th€ .0pli€ant aor slch Frmil ln tilc. siSncd slatftnl lhd hc o, ihc i\ liccnsd Pu*uMt
<br />ro ltE tmvi\ions of dE Conlr!€loar Lien*d Lrw (CttPte,9. Conmmin8 oilh Sc.rion ?000 of Division 3 oflh. Bu.incs lnd
<br />Pmfcssions Codc) or rhlr hc or sh. i. .rcnrl lh.rcfrcm and lh. tEsis for rhc alhgcd ercnlPlion. Ary violllk'n of Seritn ?01L5 6y sny
<br />smlicont lor a l. rnir suhjers lt lpplicanr lo a civil pcnalry oi nor mE ihd filc hondrc{ dolle. (1500)
<br />-l-h
<br />o*i.rofihcpn,Fnl,ornry.mploylt\wirhwxsc\asrhcnv,b.o rr.nsarior.qilldorhcworla lrhc{M1uEistrn
<br />imcMrd orrn rcJ lnr $lc (Sn-. 70{,t- Burird* r.d Pnnrsn
<br />'\ Codcr'l hc (onlli.lm s Lic.n\.If,w doc\ nol aPfl} io m o$ncr or
<br />rhe pn'Fdy uho 6uild\ or nnprolts drrofl. Mtl who doc\ snch soll hnn\clt or h.r{lfor rhmush his or hcr.utr c'ryloy.rs,
<br />tmvn[d rhrr Nrh nnnn,vcnr$ @ nor idcnlcd or ofi.reJ ntr s|t Il, h,scvcr. rhc huikliB o, i.IlpmsnEnr is $kl *irhm oE }tar
<br />oicotrIhrion. rt* O*ncr Btrikld will hr\r thc hLldctr ol B)vina rluf lrc or \hr dit mr huild or inryovc rhc nnlrny lar rhc !uqr){ of
<br />I.*owncrofrhcpft,|tny,amct(lu\i\clyconkscrir!Qiihli.c\cd..trridocroconnrudrhclr,ljt(r(Scc.r(ll'{-An\i'(s
<br />n8l l\olislira, .:'thcCo tn.rolsLiccnscL!*docs.oraltlyr.3no*n$or|nrp.rly'h('huili\orn pmlcs rhc.co..
<br />rid sho.urrncrlir\uchpmicts$irhrComE.t)rl()li.cn*lPurmnrlorhc(i)nka.t \t.i.${tisl
<br />_l r crc rpr undcr Scdio D &PC ror G rcnson
<br />IA&IEIS:.CO!4TENSAIIAN
<br />DECLAtrAUI'!
<br />I h.rcby rfirnund& pcmhy ol pc.jury otu of rh. rollowing delarn'hns:
<br />Ihrvcmdwillroir riraCerli[colcofcoi\cnrr.scl trsurc lot workcN omFnsrrion, ,s l,tuvidc{ aor by ScclnD :]7{D ol lhc
<br />Latxtr Gic. f(, ih. F forlwre of lh! *orl n, which rhl p.rntir r\ issu.d
<br />-l nrvc and will mohllitr Norkcrs conFnsrlion insuranc., as Bquircd bl Selion l70O of rh. t2bor Code, tor rh. P.rfollrMc of
<br />rh. wrk lbr ehich lnis Frnil ir iintn, My eo.kdl .onp..slhn insuErcc @t d lbli.y num66r @:
<br />lj'.Y-
<br />-l
<br />ccnitith.l in ltE !'cdorn1nN ollhc sork aor wtkn Inis Pcrmir is hsu.d.l shru nol €q,loy any llcBo. a. !., msnncr
<br />s, 8 16 tr.om subjcd ro rlE srl6{ @n{tnsrio. laus orcdilomie Md o8E lill if I qthuld beom subj.ll to llt
<br />workc* ompcnsltion lovisions o{ Sdlion l70O of rhc t ho. Cdc. I shnll. fofltsirh oq)ly wirh lhoe Provisionr.
<br />WARNING: l:lituE lo *ue *oll.( .omFnsalion .ov.a8. n unhDfol. a.d bjed e.m0loyer to nmnEl Fdhies lnd
<br />civil fincs up lo oDc hundrcd rhousond doll-s (1100.000), in 0ddilion lo rhc dBmssc{ ds tovidcd for thc
<br />1/zr inrerc{ dd dlfmy s f!cs.
<br />DticLA&u0N
<br />I hcrchy.flirm undcr l'cnrlly oiFrJUry rhnr I m li.cn*l undcr |n,visn,n ol ChlPr& 9 (.onnnctrcirrg wilh Section 7f)0) nfl)iviltrn I
<br />.f rh. B!\in \\lnd Ptufcs(i(ins Corjc. anl ry lkcn\c i\ i'r full f(rQ dt cllccl
<br />.1 ?
<br />I hcrcby affirm undcr lcnuhyofpcrjryrhotlheE h o onrn'crtun kndi.8 ugcncy fn lfic pcrfomatc olrhc work aor which rhh [tdi h
<br />i$ucrl (Se 1097. Civ. C.)
<br />I.cnify rhnr I luvc rc.d lhis alplicalbl axl {[. rh r rhc inforturion ir.od6r 1lgrc loorylyrirhull cilyond counly
<br />ordiMtres and Sralc Lrw\ EbrirS ro blildiry conrmcl ioc
<br />brc mnri.ned pbFny ror inspcclion puqrss
<br />of thN C y dd Counlt lo c.ld upon dE
<br />*," q/z{
<br />Apt'lica or Asenl Si8oalut
<br />APPROVALS ID/SIG.COMMENTS
<br />Appliances
<br />lvletal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rouoh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Ranqe
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />Openinos
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rouqh Mech.
<br />Final Test
<br />Meler Release
<br />:L4)FINAL q,lw4 \
<br />Notes, Remarks, Etc.ut
<br />DATE
<br />Duct Work I
<br />f-------T------
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<br />tt
<br />I
<br />I
<br />kndca\ ddrc$:
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<br />lppr ru nilrrii,ln eii
<br />I rENhy a,nm undcr pcnallyoapcrjury onc orrhc iolbwinB dlthrln,nsl
<br />Demolirion Pcnnn+Asbcios Noliticarion Fcdctul RcgUarions (f irl. 40. Pon6)
<br />-R.quired
<br />l,clrcrorNorifi.,rbn
<br />-l
<br />ccnily ltu thc ,cdcral rcgul,rions ESslins .strno\ rc.Eval aE nor rppli..bh ro thh lrcJecl
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