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MECHANICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OI{NER BUILDER DELCARATION
<br />I h.Eby affm undc, Fiany or Frhty Oll I d cr.nq 6on $c Co r&rou LarM L.* aor th. fouoqing Een 156 rc11,5
<br />Busif,.s and Pofc$io. Codc): Ary Cily or Counry shth rcauirei a tEmn to @i$ru4 dlo, iatproE dcmliih or Eprir My
<br />slructure prio, ro ils irsu@c. dso Equies rh. lPplicer lor such Fmir 16 nb a signcd stli.mnl lhrl lE o. slrc is liensl pu.slrt
<br />ro rhe pilvisions of rh. Conr6ro/r Li.c.sd tlw (Ctuprg 9. Commming pith Sccrion 7000 ofDivknn I ofdE Brsincst rnd
<br />Pmf.srio.s Cod.) or rhd h. o, shc ir orcnpr rh.r.liom.rd rhc bqsic fo, $c elkgcn cx.nqion. Any violation ofSctbn 7Oll.5 by rrt
<br />ortli.air for a p.mn slbjers rh. aprliclnl ro o civil Fmllyof rcr mrc the fiw hundEd dolhB ($500)
<br />_1. I owrr of rhc popcny, .. my ct ploy.tr wirh w!e6 as rhcn $b c!tr{En$r io.. will do rtE wdt ,td tlr nffie !i m!
<br />intodcd or olilrcd for s.lc (Se.70!4. Busims Md Prolc\ridni Code, Thc 6nr&r.ls Lk n$ bw docs nol .pply l. m owncr oa
<br />rhc l,rFny wr$ hnilds or ir{rorB rtf,d.. rd wl'o d(x such so* hinscli or tcMll o. rhroush hir or hf o*n cnployccs.
<br />provi,ed fi.l such itrqmrcmnts @ ml hrcd6 or otu for $h. ll howcvcr. ttE h{ildiq or iltImwr n sld wnhin oE yE{
<br />of.onq)ldbr rh. olfln.r Build.r v harc rh. bo.dcn orpEviog rhar lE or sh. dij frn tiuid 6. iqrcw 0r polEiy fo, fi. puqbs ol
<br />-1.
<br />trs owmr ol lh. l,nlcny, m .rclusivcly conrE lin8 wnh lk.Nd .onrrd.F ro Nddd llE pmiEl (s.c. 7044. Bulims
<br />and Aorsrir Cddc:1hc Conrdcroi. Li.cnr Lav docs mlopply to an ownq ofpo0cny $ho bnilds or inlows thcisn,
<br />and *ho .ontn.k lor such pmj.rls wilh ! C.ntBclo(s) licnsd ptrNu.r lo lh. Co.lradolr Li.en* t *).
<br />-l
<br />aBeicnpl undcr Scction- B. & P.C. for rhn rcason
<br />Dllc Orner
<br />WOR(ERS' COMPF\SATTON
<br />DECI.ASAIII}N
<br />I hccby aflirm unds ffnrlly of rcdury onc olthc followinE d$hrari.ns
<br />-lhrvc
<br />lnd will nunrlnin a c:cn irtarc o, (.lnrsnr lo Sclflnsu( ld qorkcri .omrnsar bn- rs proviicd lor by Srcrio! l?(xr orlfic
<br />l-rtxtr Cdc. rarrhep.rhnrDnccolIhcwork r'or shich rhc p.rn ir (\ucd
<br />-Z-n*. ,,,r *,rr -,, 'n',
<br />i" * "rl(^' con'r.c n\d ion rnqnJmc. as cquncd hy scclnnr J7(r0 ol rhc libor (ildc. ror lhc ,.rronMn.. o,
<br />rh. sork for qhich rhi\ t4-.rmil i\sulyl Mt*orkc6 c.trrp.n\rlioo iNurlnrc crtricr !dF,licynumhcr ar
<br />U// oll )0
<br />-l
<br />ccniryrh0' in rh. pcrl'ormancc ofrhc work for which rhir t).rnir is issucd. I sholl nol cmployany pctron in ony monncr
<br />so s b rx$ft \uhjc.r t ihc worlcr compcnsortun luws ofcolihrnia. und agEc rhut irI \hould bctum slbFd k, rhc
<br />wnrk6.omr..\arirnpn,visio.sulSc.rion]70oofrh.t:horC.xicIsh.U.fonhwirh.onplywhhrhrFpmvirions
<br />WARNING: I:ailurc lo sccurc workcr mnrDcnsition corerrBc is unlNtul. ind shlil sul'rcd an
<br />Codc- inrcrcsr ond llromy s
<br />o^",2'ZO
<br />I here5y .Ilm und.r p€Elty of p.,jury th.t I m lieisd lndd Imlision of Charrd 9 (.ollmBirg sitt Seli,n ,000) of Diviion 3
<br />of rl* Bulirc$ and Profe$ionr Codc, .rn n, lkcM ir i. nill foN .id .,Icl
<br />.*",,*,-47StAzc/
<br />cQNEIAlJCUoNr8Alllli.AqEX(I
<br />I h.rchy rflnD under prtrllryotFrjuryrhlr lhcre ix u con(rudio. Lndins ascrcy lor lhc psnn'uncc otrhc *orl li' *hi.h rhi\ lcrnir i{
<br />nsu.d is.c 1097. Cir C |.
<br />llfr,cf s Nrnr t
<br />AffTICANLDE.(:IAB,I.IOB
<br />I rf,'rhyalllrntr crnorll,orprrjn,o col rl[lall,)qin[dccIrrri,n]\:
<br />Dcn'lirlon Pcnnirv slrnos Norin. ir F.dcnlRc!trliion\ ( lirlr J0.l'rn6l
<br />kcqun.n l.drcror Norincari,,n
<br />I c.niryrhd rhe fcnrrll ,cEuhrn,ns rcsudinE rrhcnosr.ftnalrrc nor lpplicrblclo rhi\ pmrc.r
<br />'#r."^rhaEEod'hiiaplrd lhd rhcrtrvc inturnwnnr n concd.l.8le lo comtl, wirhlll Ci
<br />rdrc tlw\ rldiDB b buildirg.d aoL,flj hcrubyaurt!,.ir q'es.frIjrqr ofrhk Cily d
<br /> nrll.r r or s.nr Si!narurc
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Com pressor
<br />Misc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rough Ductwork
<br />Vents
<br />Joilet Room / Clothes Dryer
<br />Residential Range
<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 />Rough Mech.
<br />Meter Release II J -,a.FINAL .L ZflZ ) DIH\'rn--+rd-/
<br />Noles, Remarks, Etc.UI
<br />Furnace
<br />Final Test
<br />rhovc mo(iomd ,mp.ny fo.
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