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t? <br />M ECHANICAL-INSPECTOR RECORD <br />APPROVALS DATE IDISIG.COMMENTS (r\vFrElt Bt,It.Dt:R Dr.t.('Att vnoN <br />I hcrcby aflirrn unrlcr puralty cf lrrjury thrt I un c.rcn4lt linru tlrc ('ontnclors' l.tcenre Lmv for the follorvirry rcos(rn (Scr 70J1.5 <br />lltrlrnesr onrl ttofesrion Crxle): An1' City or Couru1 s'hich regurer a pcrnri lo conttrucl. alts. tmFlrove. dcmulrsh or rclnr rurv <br />strucluL^. [rilrr to ils ]rqnmc. uhro rcqurs thc rpplrtanl ltrr rrr,ch FErmrl to lilc n stgncrl 3lilctu$ll tha lr or shc tr hccnrc{ purcuanl <br />lo lhc pursiors of thc ('olrtr.rlor's Lrtgtr*tl l-rrrr' {(Jralrtcr 9. ('olrurrcrrirrg rvith Sostion 7000 of Divsron J of thc Butircs arrd <br />f\'ofersionr Codc) or lhal hc or shc rE Gtcrlpl thscfronr and thc bcss for thc allegcd rsunpr(to Any violstxrn of Scrtion T0.l l S tr-v Rrt1 <br />upplicnnt firr u Jrannit xuhc'ctr thc rJrplrcartl t.! u civilpcrurltv rrf rrot mor€ thul livc hurdrcrl dollars (3500) <br />-1. <br />os olrncr of tlte proFnr\,. ot uty crplo.\'ccr $ rtlr ruagl: ns llrcir xlle curn;rrrstiorr. rrill dr tlr uurt und ttrc slnrlu€ Ei rrrl <br />rnrcn&l orollercd firr mle (Scc 70.la. lltrsinrss rmtl ltofcsskrnr Codc' 'l'hc ('onltrclrn's Liccrut'Lsrv dorr D(tt s1Trl'' io on ouner of <br />tlrc pmgrzty sln builds o( tn{x$vcs ltrcroo. nnd uln rkrr; nuch srrt hlrntclf or hcrsclf or tlnough hrs or trer osn employcts. <br />por idal tlrar such iulxororxr[r ac oot &rtordsl or cil'll'rsl (r rulc. l[. lrosocr. tlrc hrildirry ot itnplot'errrrrt is rold ntthtn onc )tru <br />of conqrldbu. thc Otrrcr ttuilJer rlill lnuc thc hrrdcn of proving tlrar lr or ihc drd not blld or impuvc the popcrtl' ftrr tlrr prrps of <br />salc). <br />_ .1. is orwlcr of t hc F(rlxrly. lrrrr cr(ltr$rlcly colttrurlrrrg rt ilh lrcelrrl currlrlrlors lo cottrltu('{ t lrc ;xo1rt (Str 71X4. Busrn<'ss <br />urxJ Pnrfi-:rrrirCrrr.le 'Flrc('orttractor'sLiccnscL.rrvdor:rnorrpplyt(,iul()nnuufpolxtlvtrlrotlurldsorintprovestlrcicr.rtr. <br />arrd rvho conlr'ocls for guch llrojocts rvIh n ('otrlroclor(.$) lrcrucd prnsu&rl ltr the ('ontrt(rot's l.uensc I art I <br />B &PC ftrrtltrsrcarxlu <br />I )irtt On nrr' <br />\\'{ }lt K t. l!.S' ('()r\ I I'l'."\ Srt'l' I ( ll. <br />I)T:( L,\RA I loh <br />I hcrcg rlTir ru urrdo potolty of Jn.iurl'onc of tlrc follorr irrg dcclar otionr <br />__ -l har.e end rvill mrirraio r CorrficateofConrrrt ro SclGlmus3 f97 nrrrkar'conpct[rtton. Blr povidol fol by Scctiort.r?fl) of tlr <br />Labor ('odc. for thc Frctfonrrmcc of iltc rtorit for uhich tlrc putrit b lroucrl. <br />_l <br />thc <br />hate and rvill rn.ruttgin rvorkot' cotntlctuntton insurlnce. as bv Scctron -\7UO o, the I Htxrr Crxle. for the pttfrxrrmrrc o( <br />rrnrk frrr rlhich this pernru rs rssuod. lly rrortels'trlcc carrler nnd polrl'nrrrnbcr re <br />Polio I <br />-*ptr*: <br />t t <br />_l cerrif) that in thc pcrbronrrc of thc s'ork lor *'hrclt thrr ]rcnnrl is issue<|. I shell n(rt snpk)y sny ptrvJn rn sny nlrtrurtT <br />$ as to bccomc arbtoct to thc so*crs' compensation lnws of Cohfornin. and $llrcc lhil if I sh:ukl hxortrc sutrlcct to thc <br />ruxkcrs' conlpcrrsrlton pror irions of Scstrrn -1700 of rhe Labor ('odc. I rlurll. furthrrrth cornpll u rth llrurc pulistotts.I <br />IVARNING: l;nrlurc lo arcurc rlorkclt'comFfl*uron cr'\'erogc s unlnsful. antl slurll rutlctt ou onpkryr to crirnrnal pctnlttcrpnd <br />crvrl frnes up to one hunrlred lhousantl dollrr (Sl()0.0t)0). rn co( of cornpensatton. darnagcs rt Jroridcd for the <br />lio'tion 1076 ol'('cxlc. iutcrcrt and rtrorne1"I t <br />(I- <br />l)ate: <br />I hcrcr,! aflirnr undu' penthy o[ Jrrpry thut I arn liccrBed untlcr pulilion ol'('hoptcr 9 (comrtrcncing tith Sccrion 70(U) of Divtlnn .1 <br />of rtrc Lttrrinsr and Profcssioru ('odc. nnd tuy licauc Lc in full forcc ald c(fecl <br />b 4 <br />;;'"" q,!jlTota $L A9+ <br />perforrnolre of the rrork hr rr hrh lhis grrmrt sI lrcrttr. allirnr urrdc pomlty'of pr.iury thet lhcrc rs o conslructirn Lndrog a6cnc) <br />rssuctl(Ses. l0)7. Crv. C.). <br />l-cnrlcr's Irnc <br />-_t.crxlsr'r Atl&c:r <br />A,,Pt.l('Alilt t)1.:('t..rRATloN <br />I tnehy.nlfrnn unrltt lnrnlty of pmlury one of thc follorvrrrp rlct'lnraions <br />Llanolilion Pcrruir-r\sbcrtor Notificaton liedcrnl Rqgolationr (l itlc 40. Part0) <br />Required Later o[ Notilicatron <br />rcguding osbcstor rcrnolal arc n()t ryplictrtrlc lr"l lhrs proJ6ct <br />inforrrurtion it comt{ I ngrcc to ctvtrttrlt rr ith all ('it.v nnd ('ounl1 <br />rbove mcrrrnncd po6rty' for <br />sulhor uc r cprclcnld r.'..1 f thrs ('rly rnd <br />A;r;tlrralt or Agtrrt Signnturt <br />Itcr rurlcc narrrc (prtntl.N <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 />Roush Ductwork I <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranse <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 \\ rot\r.r tap{nrtlr <br />Rouqh Mech. <br />Final Test <br />Meter Release I I as u <br />FINAL tO\W/l hI\"H 't/ <br />Notes Remarks Etc. <br />t <br />I <br />I <br />?_