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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrcby &tfrn uodd pc!.lry oa pcrju.y rhm l m ercmfl fion rhc Conlelor Ltccn$ La* fo.lh. followi.g Emn (s€.7011.J
<br />Businc$ sd ftorcssion Codc) An, Cily or Counly which rcquiEs u l,cmil to .onsrrucl, !llc. ihtrovc. &mllrh oi Eprt dt
<br />smdoe. Fkrr ro ns nsure. aho rcluirci rhc applicel for rkh ltrmi ro fih ! signcd shtcmn rhal lE or .hc i! liccnscd l,uBudl
<br />ro rlE Flrision. ofrlE Contr.cbas Lkcned l,w (Chsprn 9, Comcming wirt Scction 7000 ofDivision 3 oflh. Busa.css and
<br />Prefcsions Codc) or rh"r h. tr shc is .rcq,r lficrciion and rlE basir for rhc dlcg.n c*nprion. Ahy viohrionofserbn 70J 1.5 by rny
<br />ag,lionr lor a Fmit $bj61s rh. lPplicer lo a civil ,r.@lry of Nr tur rh.n frve hundr.d dollos (S500)
<br />-1.
<br />ss owncr of lh. prlFny. m ny cmplolNc wilh wagca a rh.t $k omp.nslion, will do [E *ort ui llE $ra1m ic ml
<br />imcidcd dr oficrcd for sL (Se.7Ol4, Auies lnd Profc$ions Codr: Thc Conrrdn r Lkcnk tl* doe. mr ,fl,Iy lo M owncr of
<br />rlE Imp.ny wlE builds tr nrymc llEotr ,rd wno dGs uh m* him*lf or lErslf or lhou8h his or hcr o*n cmployccs,
<br />povi(M lnlt such ihprcErnlse ml inLD(h or ofcr\l for eL. ll l[wcE,lh. boibirg or itrpmwr issld*ithhomy@
<br />ol onpklion. lh. OwEr Buiids wil h!rc ll* hrn . of rmvhS thd h. or sh. di.l mt boild or inpbw rh. pbFny lor lhc p!'F,s or
<br />l. rs owtur orrhc pmpcny, dcxcltrsivcly.oota.ring sirh lien*d c.nr.a.bF ro.on$ru.r rh. rejcd (Sc. 7(}ll4. Busrnc$
<br />!.d Pmftsin Co<le:1tc Conrracrois Liccnse tie docs nol apply ro 0n owncr oiploF ry who builds or anrpn!.r lhcrcon.nnd who.o.hckrorru.hproFdswiln!ConrB.ro(r)liccnsdtur\udtrorh.Cotrtd.tolsLh.nstir)
<br />I ancrcmor undc, S6rion . B & PC fu rhn Eu,n
<br />SIIBf,ESILCOMIEIIAIIIIB
<br />DECLASAIION
<br />I lErcby af,irn unde{cnaly of poju.y om otrhc following dc.lqarions:
<br />-l
<br />havc !d w ill N irrai. r Ccn ilrarc ol Conrnr to Scll-l nsure tu worlicN compeniar ion. !\ pmvidcd l(,, by s{r i,,n .17( ofrh.
<br />tihor (lic. hr lhc lrnanM,rc oithc work lor which rhc lBmn ir hnrcd.
<br />_l hale lnd uillnlintri. wo cs conlrcnsor ion insunrcc. os Equircd l, SNrion 3700 ol rhc Laho, C.de, for $c pcrlorM. ol
<br />rhc *o for alth thic p.rmit is issucd. My workds ompcns.lion insurlmc ffi( ad ,.!icy nlmbet @l
<br />9Lz
<br />-l
<br />ccn ify lhol in fi. p.rrormna of fic work for whth lnis !.rnil n GsEd. I shall rcl cq,loy !fly p€m. in an, nn.r
<br />s as ro h..om slbrc.r to the qort6 .on{rnsdrion ldws of Cllifoni!. md og@
<br />'hrr
<br />ir I stFuld t com subiet lo tlr
<br />worlcn conpcnsrrio. povkionr ol Sdrion 3700 of rhc tllior C6dc, I *hru. fdhwnh.onq y wilh rhos pmrbions .
<br />WAnNING: F,ilurc lo suc workcn compcnsotion cov$n8c k unlastuL ahd shdl rubicl an cnrplo}f! ro ri'ninal Fndtix md
<br />civil fincs ut ro orc tundrcd tholsld dollan (1100.60). in addnion lo rhc co( otcotrqrnsalion. da@les Lr providcd 16r thc
<br />Scrn,n 3076 ofrhc tilDr Cod.. intcrc( and lllorrcy's x /tb*n.1.3r-\l
<br />LJCINiTILCONI&ISIAB
<br />DIS.II.BAIIOI
<br />ol rlrc lttr\in(s rni lt lrsi,ni\Colo. rn(t n,! li.ctr\. i\ i',lnllturc. rtulrllc.r
<br />a -79 s55L
<br />f<P
<br />C(TNSTRU(ITIoN I F-NDIN(; AGENCT'
<br />I hcrcby rflnmudcr ltmhy otr--rjury lhd rh.rc h n con{ru.li,n bnnirs rscn.y n, rhc FrfonMncc orrhc *ork hr $hi.i
<br />'hN lEirnir ir
<br />r!\urd (Sd. :1097. Civ C r
<br />A.ITLI(:IIITLI)}JII.AAAIO!
<br />I lrr$y rinnr trn(lcr r(rrlry olncriury onc oi'hc inlhq ifa dcclirrr .n.
<br />DrnxilIi,r Fcnnir\ Ash.no\ Norilicrri,,n I:.drrxl RcEUIri(ntr (Tirlc lo. Pd6r
<br />Rcqunrd L.lrcrol Nohli.di,
<br />-l
<br />.cnify rhlr rh. fcdcml rcBul,rions Egsding sb.stos rcmwl m mr uPl,liqbb Io rhis pejecr
<br />l cniiy rhdr l hNr r.,J rhis ,tplk.tion oi sr,rc th,r lho $ovc inroamriotr is conccr , .Brc to comt'ly *irh rll Cir y and Counr,
<br />ordina cc\rid Srrrc ljw! rclnrin! b buikling rcr*scdhiivcs ol rhk Cny md County lo cnlcr upon ltE
<br />nh,vc mnrnrncd F)p.ny rur
<br />Aftlir rorA8cfr sigtrdu 1- 7r-l
<br />Pmiree ratu (Itriir){I ., t-
<br />Appliances
<br />Metal 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 />Rouqh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Ranqe
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Fire Damper
<br />Openings
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.4/4//?rt/nbrlL 167--
<br />Final Test
<br />FINAL 4///rq A/llMfil /n)
<br />Notes, Remarks, Etc
<br />-+
<br />Grease Duct
<br />Meler Release
<br />' ,o-t-)8
<br />arnnv'<
<br />o"',,'7'31-I* c*r.*r..{ 6 r, *" -
<br />-=-
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