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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I h.rcby anirn lnder ltdlr, ol pcqury rhll I m .xenq fioh rhc C.nnid6B Lk.M t w tor rhe followi.S p!$n (Sa.?03 1.5
<br />Busin.$ rrd Profcssion Cod.): Any Cily or Counly which rcquiEs r Fmil lo 6n(toc1. 8lld. iml'orc. &mli{h or q{ir My
<br />srrudtrc. !rb. to ns issuam, abo bqutc$ th€ dt plica for skh Fmn ro 6lc a riEed sr.|.mfl thlr h. o, she i! lkered pursdr
<br />lo lh. Fovilions of lh. Co.trstols Lk.n*d ljw (Chaptc. 9, Com@min8 wiln Selion ?m0 of Division 3 of lhe Business tud
<br />Pof.ssions Codc) or th.r lE or shc is cx.mpl rlErcfrDn .nd rlr be!i. lor th. allcScd crcn tion. Atry vioLrion of Setio. T0l t .t by ony
<br />lppliconr for a pemir subjects rhc rDpli.ant fi, a civil pe alt, or tur mE lhM fivc hurdGd dollar (S500),
<br />-1.us
<br />owncr of lh. I,mFny. or y cmplorrcs wnh wrg.s trs llEir $lc mnwnsnrion, oil do llt wo* an . stillm i mr
<br />in|cdd or oficrcd for $lc (Sa.r044. Busincss and Pmfcssions Codc llre Conrrdofr Li.ns. trw docs nol +ply to an ovncr of
<br />rhc pmJEny whot ildr tr nrFmrcs lhcmr ed *io des such mlk himsll or hchclf or rhouBh hh 6r h.r own cnplorecs.
<br />pmli&d rhar such imphhrcnEm mr i cn&d oroll.En br sk. tr. ho*.w, fic hildin8 or itrprowmnl is sld within one ld
<br />olonpknion. rlE Owmr Buitlcr qill hlk rlt hidc. ofpmvinS rh,l tE or ste did ht boiu or inlhw rhc pnldr, lot 0E plrlbe of
<br />_1. Nownoof rlE poFny. m.rclusivcly.om6crinB wirh liftns.d.onhdou ro $.strud llE rmjccl (SN. 70{4. B!{ncrl
<br />an! PDfeasbn Codc: Thc Conrracroas Liccnsc Law docs mr lDrrly ro d Dw.er .r pr.pcny who builds or improvcs thcrsn.
<br />lnd who .o.a..k ror su.h lroFds *irh s C.b'mcro(s) li...ed pursur b rh. ContB.rols Li.rtrc L!wl,
<br />I DDcrc.rfl Dndcrsccrio. ,B &PC forrhislcrsotr
<br />III86E8Ii:CAMTBTAIIOX
<br />[ECt A&rtrO!
<br />I h.Eby aflm undn pcully of p.rju.y.B of llE huowirg d6l,Flioos:
<br />-l
<br />huk ed eill minrain ! C4nifprc of Conrcnr to Scr.lniuc fd sort6 omp€nelion. a\ povlH for by Selion 3?00 of lhc
<br />Labor Cdc. for lnc lcrforneru of lhc work for whkh thc l,smil is irsrcd.
<br />_, halc rnd willnmirrair so,kcn conrcn\llion .s reqli'td by S*r ion ITOO of lhc Lrho, Codc. for lhe I,.rfomNc of
<br />ldion insurecc coir aid policy numb.r Ec:rhc lqk lhr which rhis pcmir ir hst n Mr wn,kcr
<br />-l
<br />cenily ltal in ttu Fcrtormncc oallE wori for wh rhis Firnir h irsucd.l\hallao' crok,yany l,jison inlnynoncr
<br />v, tr hcg'm \ut'jsr hrhc sor\crs.unpLnsdn,n ., Califomia &d aSm rh8r ir I should lx.om subirl lo l,E
<br />sorkcrl comp.nsrion pn,vni,N ol Sccrion :1700 of rhc tnhr Cdq I shall. ionhwilh .omrly wi'h lho* pmvisions.
<br />WARNING: Fsilurc lo $curc wrlcd ory).nqrk,n ovcnsc is unla*tuL and shdll snblxr ,n cmplor{r io simi,ol Irnttts and
<br />UrENU'Dll)Nr&}gAts
<br />Df,CLAB,IIION
<br />I hcrby affifln!nd$ Fnahroalcrjury'har I rn lienql !tuicr ior of (naflr 9 (ommrcing withScclion 7000) ofDivnion l
<br />of
<br />'hc
<br />Busim$and Pmfcssions Codc, lnd dr li:cnsc h itr
<br />Toltlt"l
<br />o",_fu4 r<-
<br />COBEIA!]CUI}BITAIIIIIGIIiENCI
<br />I h.nby Itrm und.r F.,hy ol Fjury 'h!l
<br />rhm h r mnsrudb. lcndi.S !8crcy fo. lhc pcrfotukc of thc wor* for whi.n lhn ,mir is
<br />isru.d (s( :1097. civ c )
<br />6TTLIIANLI]ECLASAIrcN
<br />I trnby Jilnn undc{Ennlr} of p.rjury onc ol I h. folbwinS dr..leat ionsl
<br />Llcm,libn Pcrnirs Ashcsros Norificornr Fddcrul Rcsullrions ('tirlc 40, P!ri6)
<br />-Rcqrircn
<br />ldur.l Norifi ori.n
<br />-l
<br />.enify thar lh. fsdcrrl rcsuldions rcgeding arhnor .ctuvnl Bc tur ri]lli.nhlc lo thn pmjer
<br />-l
<br />ccnily rhlr I hnvc rcnd rhis uptli.arion dd shrc rhar rhe Blovc info,uion h c6rsr. I e8re rommply*ilh lll CilysndColnry
<br />orninoDccs atrd Shrc tiws
<br />abok mntn,ncd porcny
<br />ro buildins co.sin,dion. and hcrchyluihorirc Epr.snriiv.\ .r rhi\ cit! nnd Countylo.nlc! urotr rh.
<br />Applt l or Agcnl Si8nor I
<br />J)
<br />I
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />lvlisc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rough Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer 7-n-tt k.W.1tl
<br />Residential Range
<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 />Meter Release /a)
<br />FINAL )VW.'1lbl
<br />Notes, Remarks, Etc.u \-/
<br />Other
<br />*lCcl
<br />(Nil finc. ut r' onc huntl,cd rhousnd dollar (!10+000). in sddiri.n ro rhc..i orconVEnsrio., d.,M8cs as [ovided fo.lhc
<br />Sccrion:1u7oo,Ihc L{bq C.{c. inrc(r and urhrmrslrey'
<br />'.,", .7 !rl lrA 'ou"y['1-.--- -
<br />L4z
<br />t---+---
<br />tt
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