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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrctry affrm undc, p..ahy of lcrj!ry rhd I u cxcnifl fram rhc Conrados Li(M L{w for lnc follo*inB Een (Ss,1031.5 <br />BusiDcs and Pofcssion Codc): Any City or Counly which r.quircs ! IEnit lo snsttocl. rller. irt rovc. d.mlhh or E!€r sy <br />std.rN. trio. ro ir issuatuc, .ho Eqlircs rhc alpli:air for such Fmil ro fik ! sis.cd sllrcmd $al tE or dE b lic.rEd puEa <br />ro thc pmvishtrs ol thc Contrsclols Licnsn Ll* (Ch.rr.r 9, Commrcing vith Sslion r00O of Divhhn I of rlr Burine$.nd <br />Prfeilio$ Codc)ot rhsr h. o, shc i. ercBnl rh.riiondd rhc blsh for rh. llhg.d dcnplion. Any viobiio. otSetion r03l.5 by..y <br />oppli.aot fo, r p.mjt suhjec rhc atplkr ro..ivil p.mkyofnor me rhln liv. huodrcd dollr3 (S5m). <br />-1. <br />I owm, oarh. prcFn, or my cnplorrcs sirh wrBcs s th.L slc com!.nsuio.. s do trE *6k ard rlE nrEl@ i{ ml <br />inlendsl or of.rcd ror sh (Se ,o,14. Suiims r.d Prcfcssbn. Cod.: Thc C.n!reloas Lian* L!* docs nol 8l,t,ly lo .n owtur of <br />rh.!6Fny sho buildr or inlhves tlEe., and who d@s $ch slt hinself o, heelt or rhhugh hk or hcr own cmpn,)cs. <br />pDridcn fi.r srch iqmtrnrs e ml hrcndcd orotu fm sle. l( h.weE lhc hildios or i,rlftm'n t sli eirhin @ Jet <br />ofon{rldi,tr tlr Owncr Buinc. sill h.E llf, hnd.n oftmvi.g ltul lE or slE dA ml tuild or ir{,oE lh. Fmtsry for llE pqn* ol <br />-1. <br />!soBmrof thc tmFny, rmcxclusirlym mcrinS wirh lic.n$d conrrlcrosro onsrud rh. !totrr (S.c.7044. BliiG$ <br />!.d &nirssir Codci Thc Conrr&r.r's Liccos Law d.es n.r arply ro e own$ ofpmp.ny *ho builds or ihrrovca lhcr6n. <br />lnd wn onrBcls for such pmi€ls wirh . C.flaclo(, licMd pul:Mr ro rh. ConrBclm s Li.us. L.*). <br />I In.rcnu undcr Sccl <br />l)Hr. <br />J!I]8trE&i:.CAMTEN'AIION <br />DECI.ASAIION <br />I hctby affim undcr Dcnlhy ot psjury onc of lhc follovin3 dsbralions: <br />-l <br />haE sd will einroin s Cc.rifrat ofconhr ro S.tf-lnoE for m s otrDcnsadon. {. Din dcd forbystrlion l?ooofln <br />Llkr tuc. fm lh. Frfollr]m. of lh. *olt aor which lhc Frmil k issucd. <br />_l halc and ,ill iainloin oortcrr' .onpcNarioi insrEn.c, 6 rcqlircd hy S€rion lr0o or rhc trbrr Codc. fo. E p<rfo,mrcc of <br />rh. work lor whi.h rhh p.nnir is hsucd. My qorkcn .on{xniarion insumncc c6icr ud fnicy trumbcr dc: <br />-t <br />ccnitilh0t in lnc pcrii,rmrcc oflhc wort fur qhich rnis pcrnil is issued, I rhrll nor cntl,y roy !c*on in any mankt <br />s ar io tr.$m sxhi(r ro lhc sd(6 smlrcnelon hw1 or Calilornio, and sSEc rhnr if I sh.uld tE om subj.{l lo lhc <br />so*s{ @r{Ensali6, pevkions of S.ciion l7O0 of lhc Lrlbr Codc. ! sh,ll, fodh*ilh comply wilt llss povhk ns.. <br />WARNINGi F.ilorc lo sm work R' onlt.nsdion ar@E is unbwtul. snd sh.ll rubirl d cmpbF lo diniml Fnlb ard <br />.ivil fincs up ro o* nundrd rhousn<l dollss ($100.000I h lddhion ro rhc .osr ol.onlltosrion, dlnEgcs .s phvidci for dE <br />Scrion 30?6 olrh. bbor Codc, intcEsl lnd alromy's tN3. <br />D.l€: Appliotrl: <br />ucr:xuil)laNllJ(loB <br />Dt;.cla8 rllrN <br />or rhc ltusinc$ and Prnt$b!\Gnlc.fll my licctr\c is in rillr(trc. rndcrlrr <br />D.lc: Ct"l <br />CAN$ITIJI:II{]NIINDIIC.&EEXCI <br />I h.Eby rlttD u dcr lxMlty of F.jury ln rhsc is i .onstrucrion Sndnrs rBck_y for rh. Itrfqmn.c of rhc wor* rot whkh rhn tf,rnil n <br />is\u.J isc. -1097. Civ C.). <br />AIIJ.ICAtrLUICI.ABA.IION <br />Ihdrtry flinnund.rr.nsxyofp.rruryokorrh.n,lh*nrgdsl {idrsl <br />Dc,relition Pcnnik-A\b.slos Nolific.lio. ljcdcrrl Rcgulrrions Ont 40- P!n6) <br />_Rcqrircd l.rrcr oI Norifi crrion <br />-l <br />cerify rhit rlE lc&ol EBuhions Eg.rning asb6l6. Emval @ d ,ppltlbh lo this pmj.rl <br />-l <br />ccniii rhlr I hnvc rcad rht lpplicdion snd stlrc rhal rhc stnvc infotufion ir comr. t lgc lo cotrply with !U City !d Colnly <br />odimes and Siorc Las. Ehri.e ro bui[nr8 .o6hcrbn. sri ]rBbysurhori.Epre* aircsoflhi.C y and Couniyro cnr6 upon rtE <br />lbovc mnrion d Im!,.ny lor i.sFcdion I[rIDsB. <br />lm e nJm rpirnl <br />Appliances <br />l\lletal Fire Place <br />Evaporative Cooler <br />Furnace I V7.1Eh(,-1 fY" <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork ' Ltoh,fr/Aq>-/b-- <br />Venls <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 />Openings <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech.I Ah frrt^ofB,-tg> <br />Final Test <br />Meter Release <br />FINAL &IU tA C.tv\frn - ,(\ -/ <br />Notes, Remarks, Etc <br />tk <br />0 <br />Applicur o. Ascnr Sisnaturc:- <br />I <br />I <br />tttt <br />= <br />=