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MECHANICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNEN EULDER DELCARATION
<br />I lErcby affirm undcr Fmlry of !€rjrry rhir ! m cictr{,r 6!m rhc Contr..los Liccoe L!, for rh€ followi.S ..sn (s< 7Ol I 5 '
<br />Busi,csr .r{ Prolcsion Codc) Ary City or Coumy whbh reqliEs ! Fmir ro onsldcl. dl6, improrc. d.rchh or t,!n y
<br />sttucr*. pri,r lo ns nsuakc, al$ rcqlncs rhc appli.ul for sEt Frmir ro lih ! sisdd sr.reft rhat h. or shc is liccnrd Furslnr ,
<br />lo lh. Fovisionr oftlE Conlrebls Lic.nsd Law (ClBplcr 9, CohmminB *ilh Sslion ?Om ofDirision I of lh. aurincss a.d
<br />Ptufr$ions Codc) or thlr lE or st* t cx.hpr rhcEfrom s.d rlE bssiF for rh. allcg.d crcrgrion. Ary viokrio. of Sdtb, ?0.t1.5 byuy
<br />aptlicait tor a pcnnir subjds the ltplicdnl lo a.i!il l,celr, ot mt mE rh6 fivc hudrcd douos (S5@).
<br />-1.ac
<br />ownr.frh€prcFny. my cnplojEs wilh wa8cs ar rlEi $lc@mp.nslior. *iI.lo thc*ort a llt*ltlmiiNr
<br />ime'd.d or oftcrcd fd sL (Se 7044. BlsiBs .nd Profc$ions Codc: Tlr Conrtuloa. Licde LrB {k'.s m! .p!ly to s owmr of
<br />tncpmrEnt who builds or trFm!.s tlEmtr rnd wlb do.s 3uch mlt himsclf or h.n.lfor lhmu8h his or hs own cnphrci.
<br />pmvi.hd lhd.uch ia'IroEr ! & mt i.rdrHorolf.Ed fo. slc,lf.lE*cm. tl.t t{iuingori.FroEm k$ldwithhomFd
<br />of @npLlbr tlE o'rM Builds qiu har tu h,rd.n of p,!li4 oEr lE or shc dij hr hiild or in+or UE t trIEr, for tlE purpos or
<br />_1, N owftr ofrhc rmpeny, amciclusivcly.onracrios sirh liccn$d coorar66 ro mn{ocr rlE tmirl (SN.7044, BNm$
<br />ard Eofa\ion Codc Th. Co r.clolsLic.nr.Losdocsmr{!!lytoatropncrofrnpcrly*hobuildsorimtolcsrhcrco.-
<br />ad *lD con|flds forsuchIlrjers pirh ! Co.tEcro(, liefl*d plnu lo rhc CoflricroCs Ltcn* t w).
<br />-l
<br />m cr.ofl undcr SeriorL- B. & P,C, for rhis Ea.on.
<br />YA$EIIECII4fENI,AIIAN
<br />DECI ARATION
<br />I h.r.bt ainrn und.r rcnrlry or ldjury o.c ol rh. folb{irg dshrari.nr
<br />-I
<br />harc rld willdinl8in a Ccnificarc olconFnr ro S.lfinsur. ror workcG ompcnsarion. * Folid.d for by Ssrion l?0O of rhc
<br />tihor C.dc. ro. rhc Frfr)mNc oa llE wo* fo. whih tlx Fmi, h irsucn.
<br />fi";*;lllir.intsin workcrs .omrcnsarion insumncc.0s rcquncd bySccrion 37(Xrotrn€lj$orCode, for rh. p.{or@n.. of
<br />lhn pcmil h issEd. My *ort6 coqEnsalion iNumm fficr dd ,nlic, nrdbcr e:
<br /><:_
<br />_l ccnif, that inrhc FiformNc oltrxvork aor*hichrhi*Frn h kskd. l shall mr enploy lny pcMn in lny maflncr
<br />s Ilo h.com subi*' to lh. vorkac omrBnerion hwr of C.liforni!. ofld lee ltol if I sbub tt od 3lhjccr ro rhc
<br />worr.rc'omFnsrlio.t6vkio.sofSetiotrST00oflhcL{borCod..leh!!l,fonhwilhomrly*ithltosprovisio.s..
<br />WARNING: Frihrc to suc sortc6' odptn\di6. cotBsc i$ !.lawtuL dd rhnll subicct on .n9lorlt lo aiminal trmhts lnd
<br />civil fin s up ro onc h!.drcd rhoueod dolld (S100.m0), in addiri,n ro thc.os or.onqEnsalion. d!.E8cs !s lrolilcd for llE
<br />€Applldnr: / z-
<br />LII;DIIEI]I;I]NIAA1:IIIB
<br />IIEIIdAAIION
<br />I ncrcbyafiird undcr lcnahrolpcrjury lhrr I !m lntir{ undcr rn,vilnrnolChaprur 9 (..mnEncnr8 wilh sdn,n ?uxr) oiDivnion l
<br />oi rhc Busiocssrnd Pnra\siors Co{lc.0d nryliccnr n intullfr.c {rrd.flNl
<br />E c <1 e96
<br />? .."-",o" -
<br />CONf,If,IEUONIENDIIC.&OINCI
<br />Ihcrcbtafitnrr.rnnalryofrrrjuryrhdrhcrcissronlrtucii,,nLdin!rsci.y(trrlrF,rri)nnm.coirhcMrkturtrhi.hlhi\pcnili\
<br />nnd (Scc 1097, Civ. C.r
<br />AIILIIANLIECI,IBAIroN
<br />I lf,Nhy,finn un{l$ lr.trrlry of p-rjur} otrc olrhc lollowins dc.hidn,n(:
<br />Dcnnlirion Pcrmir!Ash(\ro\ Norificnrion redc.llREruhrions (-Iirlc 40, P!n6r
<br />R.qoirud tr(d of Noif.{tun
<br />I cdifyrhtrr rhc a.d.ml rcSulrions Eg,nlinB lsb.nos r.mvalm nolapnlicablclo rhis pmi{l
<br />_l .enify rh.r I haw rcld rhi. atpli.drioo atrd arc lhar rlE ,h,vc iotomrion is co,mr. I aBc ro .ompl! sirh lll ciry nd counry
<br />ordimn(cs and Srarc l-ass rclding rn huildirE .on{rucrion. !M hcr.hrruihoriz. {lrcscnrdrivcs ofrh( Cirynnd
<br />ahorc tutrrn,rcd prepcny fo, inrpccr
<br />Apdic.nl o. A8Etrr Signolurc I
<br />Appliances
<br />Ivletal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rouoh Ductwork
<br />Vents
<br />Toilet Boom / Clothes Dryer
<br />Residential Ranqe
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />Openinqs
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rouqh Mech.
<br />Final Test
<br />Meter Release
<br />FINAL I h*l/l 4vtt*u tltl -/
<br />Notes, Remarks, Etc.
<br />poti"yxu *,,@^ n'
<br />43:
<br />II
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