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MECHANICAL-INSPECTOB RECORD
<br />APPROVALS DATE ID/SIG.OWNER AUILDER DELCARATTON
<br />I hcrcby.fttrm undcr Fnally ol,,crjury lhat I m.x.hpr rmm rh. (1)nloclos Ltcnrc L3w ror the louowing rcrsn (5(.7011.5
<br />Busincs n Prohstun Codc): Any Ciry or Cohry shth rquncs a tf,mir ro .a'nstrucr. alcr, in ovq &mlhh .r rlan M,
<br />ir .rm. prhr ro ils is$afte. dho rqlies rhc spFlta for slch Fmi ro fiL a riSncd skrcmfl rlBl lr o. shc is licn$d ,uutrr.r
<br />to lh. tmviihns of f, Contrclols Lic.n*d t:p (Ch.p'., 9. Commming wilh S.cthn 70OO of Division I of tlt Busin$s lnd
<br />P,trtc$ionr Codc) or rhlr lE or rhc is cicdfl lncrcfroh ad rhe h$is for rhc lllcs.d cicnprio.. Ary violdion of Sdbn 7ol 1.5 by my
<br />lppli.an{ for ! p.mit suhjkB llE at pliconl lo e civil FmlryorNllmrc lnln fivc hundrcd dolles ($500)
<br />-1.
<br />$ ovmr oi rhc t'roltny, or ny cfrpbrr{s wirh wlBcs as rhcn $b or{u.a' io.. sill do ihe wk erd th. siEtE is ml
<br />i cnd.J or o(crcd lbr sl. (5(.7044. Busincs rd Pma.ssionr C.<lq Thc Cont|.dt Lkcne t w docs nol lprly lo an owner of
<br />rhc pnrEfty who huilds or insrows thcNn, !.d who &Es uh mrt nimsclf o, ficrclf o. rtrcush his or hcr osn cnploy..s.
<br />providcd rhrr such inproEmnre m nor intcndcd .i ofici.d for sh. ll tx,rNcr, rtr tuir na or itrpmEmnt is sld wnhin orc ycs
<br />of.omnbrir, rhc O{ncr auiB$ will hrw rhc lrrdcn of rmvi.s rhd lr or shc di:l nor buill ., i.rpoh rhc ,mFiy for lnc pu{,$ ol
<br />I. N oa@r orrhc rrctcny. oo.x.lusivclyconlr&ting wnh lkcdsd conrreronlo snsru€l llE poid (Soc. ?044. B8in$s
<br />Bnd kr6sion Cod.: Thc ContBtoas Lic.nE L.* des mt slply ro !n own r of tro|)cny eho blildr o! inlrow! rhcMr
<br />and eho @flEfi for such FEiFrs *nh a C6tn6d6(O |tccnsd pus@r ro ihc Conturd . Lia.s t2w)
<br />I rtucxcnrtr !ndcr Sccrn)
<br />lllxtrEBt:c0!IfEtarl0!
<br />D[CI.A.8AI1ON
<br />I h.rcby affirn und& Ic6,hy of p.rjury onc of lhc rolloving d.chnrioN:
<br />I x6or Onl.. turlhcNni)flnu.. ol rh. $frk ntrshi.hrh. pcanir i\ n\urd
<br />J hsvc lnd *illmintoin workr( comp. sution as r$unL{ by Sccrnnr l?m of lhc Llbor Codc. toi rhu pc(on@c of
<br />insuruncc cndcr lnd policy nuhbq d.:
<br />-l
<br />an iay ttul in lh. plyrormmc of lh. q for which thh pcmn is issucd.I shall nor .mrio, !n, nc6on in tny nsmr
<br />s rs ro lE om strblxr io ih. worttrc onF.erion h$ or Calilo..i& nnd r8er rhd if I sbuld hccom sbirl lo llr
<br />eorr.B mrIrrurio. povkions of Sst ion l?00 or rh. tllr, Cod.. I \hall. lonhwifi omply wnh thos pmvisiotrs..
<br />1V,1RN!NC: Flilurc t, flurc qorlt.^ on{rn\rrion.a cEEc r\ utrlxwlnl ni'l \lt,ll subjd ,n .nDlorr lo aininal lf,Ehi.\ ond
<br />.r.onp.n{lion. dame.s as pmvidcd for thccivil nncs up ro otrc hlndrcd rhod\and
<br />utENtrl)_cQlit3llrlolt
<br />UlCIlBrllll)N
<br />I hoEhy dfiinn uDd.r Fnilly.fNlury thd I inr li.ctr*l uM* tnurisn$.fCh.Ocr 9(.onnrrncing *ilh Sccri,n 70lx)) ol Divni,,n:l
<br />ot rhr Ilr\inrs and Pbfr\si(nis Codo. dd nrylirci{ n ii tull for(ril(l,c.r
<br />o"", \^5\\ .-,*""
<br />II}ISIBICIIONJ.ENDIMICEIqT
<br />I h.Eby.fi.6und.r Fnallyolperjury lh thcE h r olntuclion k.ding !8crcy for lh. p.rformk of rhctu,k for *hict $is tfmn i!
<br />isrucd (56. 1097. Civ. C,),
<br />N",iiyrhd rhr tcdcralrqulari,'n\ rusu.dins !\besro\ reflslil arc norrpplicrhlc h rhistue.r
<br />rhlr I hnrc rcnd r his llpliclrion ord (0rc rhir $c fi,vc innnurbn is cotrcct I o8re b oDpl, $irh rll Ciry rnd couhr,
<br />oilinaftcs ahd Sr|rc tiws Elnrint ro buildiig con io..inlh.rlbyaurhoizcrcprcsc divcsof thisCnyatrdCounlylocnlqlljonlhc
<br />ovc tE.rioo.d pmFny lor in
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />l\4isc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rough Ductwork 1.7 tlrllQl b cflk fa
<br />Vents
<br />T oilet Room / Clothes Dryer
<br />Residential Range
<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.('r,Yl'otW ffi)
<br />Final Test
<br />Meter Release
<br />tK---'
<br />Notes, Remarks, Etc.
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<br />COMMENTS
<br />Grease Duct
<br />t1lr 0
<br />FINAL \ln,\,k ?alwt
<br />Sccrioi 3076 ofrhc libor Codc, inrce{ !.d unomy \,.",t^\x-\
<br />lrndels Addles:
<br />-
<br />appr rciiil ii,tiiirF
<br />I M,y3rm uodq pcnrlryof pcrjury onc oarhc roltowirS dc.lardiotrs:
<br />Dcmlilhn ftrmiis.AstEslos Norificrtion rrdcEl RcBlbtions Onlc40. PlnO
<br />-Rcqltcd
<br />tlncr oa Ndaf{ ir
<br />--'"'(
<br />\f-f\
<br />I
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