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APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I h€rcby dfiim undcr p€nalry of ll.q!ry Oar t m c,en fom rhc C.!hdoB'Lic.ns Llw for rh. following Mson (St.?911.5
<br />Aucincss dxl Pmf.$ioo Codc): An, Cir, or Counry {hkh r.qui6 s pcmn ro oBmcr 1116. inphE, d.mlnh or Epqt &y
<br />studr, priu to ns issutue. llso r.ldes lhc qipli.sr fdr sx.h Fmil io fih s siSEd starcmnl lhrl lE or shc t liered ,uJlMt
<br />ro rhc povkions of rhe Conlrsttr s Liccnsd Llw (Chalrcr 9. Comme*in8 wirh S..rion 7000 olDivtion 3 of th. Busin.ss lnd
<br />Pmfcssions Codc) or rtor lE or sh. b cxcnpt rlrrcAom lin rhc ba(ir lo, rhc dbecd cr.nplior. Ary yiolalhn of S*rbn 7031.5 hy .ny
<br />applice for rI'.dir slhrd$ rhc opplica 16 u civil p..ulry of mr mre tho nvc nu rn dolss ($500).
<br />-1.
<br />&\ owmr of rhc prcFny. or my .mphrt.s wnh wa8cs &s lhcir $h oryEnglk n- will do ltf, work tnd rtl slirrm G ml
<br />intend.d o. ofcrcd ror slc (Se.7044, Blsituss and Ptufcssions Code: Thc Conbadols Ltcnsc tlw docs nol !p!ly ro d 6M.r of
<br />rhc tmp.ny eho blilds 01 in{rcB dE@n. 0i vho d..s sh eD,t himslf or hcrslf ot lhouBh nis or h.r o*n.ttplorss,
<br />prolidcd rhll slct inrhrtfu i e rcl iolcrn d orolfdd for ulc If.lio{€w, 0I hoilding or i,9trmnl i. $ll wnnin om )qr
<br />of coq,Etion. rhc Owr Builds $ill haw {E budc. 6f nmttrs rhd lE 6r rh. dil mt boih or in{mw rhc Popdy ror tlE I'lqns of
<br />-1.
<br />as owNr of lnc pmpcnr. ad eiclusirl, .oor,&lins wirh liansd .odra.toN
<br />'o
<br />coosrud lic pmj.rl (S( 70{. Blness
<br />,nd Prsfts\hn Codcr Thc conrodoas Liccnsc ljw do$ nor trptly to !n o*ncr ofpmpcny *ho huild! or iipmvcs lh.rco..
<br />ond *ho coirEcts lor such ln)j6ls wirh aCo.t rcro(I li.cn{d puhurit ro thc co dclors Lic.trrc Law).
<br />I Emcxcmd undo S(lion .B &P.C rorrhi!rca\on
<br />Drt., O*n.r
<br />vaatrtrBl:cQll8iNiarlQN
<br />OSCI/8AIQN
<br />I hcrcb, amrm und.r pcndliy of pc,jury ohc oflh. rollowine dslamtiotrs
<br />-l
<br />havc ard sill tuinhin 6 Ccnincd. ol conkfl b Scll-lNur. ao. wolkcm comrcns{lio., Ls Eovid.n i'or b, sc.rio. l7m oi lhc
<br />bbn Code. for llE Frfomft. orrhc 8o* lor whi.h rh. |)cmil ir nru.d.
<br />_l h!!c rnd willnuintain s.rkcr'c.ilpcnsarion insurance, as rcqun.d bySccriotr 3l0Oolrhc L$orGnt. ntrrhclrrr.nuD.cor
<br />rhc solk l'orshichthn p.dir is issed. Myworkc( co Ucnsdrio. insurotrcccarkra policynumbcr elc*,, l/\)eSCDc
<br />-l
<br />ccflifyrhlr in lhc pcrformne of rhe wor* fo. which rhh lcrhn ir isslcd,I shlll not cn!,loy uny I'cGon in lny Mftt
<br />b N ro h..om slbiNr r. thc mrtdc mflFnMlion lNr of Clliforni!, lnd oEE rhrr if I snolu ltcom suqi6r to ltr
<br />worlGl omp.nsr ion poviqi.B .f Serion l7O0 of rhc lllrr Code I shall. fodhqilh oqlly wnh thoe poviii.,s..
<br />WARNING: Failur. !o surc workc( compcns ion covcmSc is utrhwftil. lod shall sxhlr an . llorr ro ciminrl pcuhi.s and
<br />rivil li.cs up ro oN hundEd lhouend dollsr (Sl in addni'. ro rh. casr o, co nlp..stion, darMgcs !s prorided for lhc
<br />SNrnnr 1076 .l rh. I rlrr Cfrlc inrcrcn 3nd"L_44e
<br />LICTNIf,]LCON]BACrcB
<br />DCClrrBtrIlAX
<br />IhcNhyifintrrundcrprnnlryolIrrj{tryrhJrI!rliccn{dtrndcrrm!'\tun.1Chrlrd9(con$Etrcirs*ilhSccri,n70(n)orDivtrnr:l
<br />ot rhc lru\ir$qrM Phics\ionsCodc, nJ nry liccn\c is ir lulllhrccunllllccr
<br />*,. 14-\Z
<br />l:a!$If,lJqI[)NM.lNG]tliENCt
<br />I hcEbyalti u cr Enrlly ol pc.ju,y rtul rhcrc is a en(tocri'n lcNii,r!aC.Ny n,th.F onrEnLroflhc *orl fo, whkh rhis lf,irnn a1
<br />i\suoJ lsc. :l{D7.Civ. C ).
<br />I c.dif, rhd I hnv. rcld rhis trpplicatn'n ud sllrc ltur thc ubovc informlrion t comr I agrc ro omply wirh allCilt rnd Counry
<br />{rhi\ Cny Md Counlylo cnlLr ulsn lh.lurhrnx rcl)rcscnkrilcr o a-q-
<br />n Lrc-r'n-.
<br />Appliances
<br />l/etal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rouqh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Range
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Fire Damper
<br />Openinos
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.7/rolz glg
<br />Final Tesl
<br />Meter Release
<br />FINAL la?ld s\+f/
<br />Notes, Remarks, Etc
<br />MECHANICAL.INSPECTOR RECORD
<br />Grease Duct
<br />. \-?-17
<br />L.n<Lr'r Nmr-
<br />kndcCs Addrc$:
<br />-
<br />,rpprrciiiiEiil ixrri
<br />I hst{,y alim onder Deralr y of,E jury om oi the aollowir8 d..lln.lions:
<br />D.Nlirio. Pcrmils-Asb.slos Norificalion Fcderal RcEulations (Tillc40, Pan6)
<br />-RstuiEd
<br />Lcllcr of NoliaEaton
<br />-l
<br />c.n iay lhal rlE fcn Bl rcsublions Esadi.s &qtEstos em)ql dc mr rttlicabh lo llln prcjcl.
<br />okiinr c.\ md Srrt'lxss r.l!i'rt
<br />Lz
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