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APPROVALS DATE ID/SIG.COMMENTS <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 />Yqurt".r4Rough Ductwork It 1tn 1 vr/ <br />U <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranqe <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 <br />w^ut(*,Rough Mech.tt 1/r{ I ;P)UI <br />Meter Release <br />FINAL -l Ec zi <br />Notes, Remarks, Etc. <br />MECHANICAL.INSPECTOR RECORD <br />OWNER BUILDER DELCARAI'ION <br />I lEeby affirn undr Fnalry or p.rju.y thrl I 4.xcolt nDm rh. CodrsloN Ltcn$ b! for lh. follo*ing m$n (56.7011.5 <br />Businc$ !.n Profe$i.n Cod.): Any Cily or County which rcquiEs a Frmil lo .oislrud. allo, improw, &mlhh or rpair my <br />srrudN, rrbr b tu irsuare, at$ rcquircs thc +plicDt for 3un p.rni b nk a siBftn arcm thll h. or shc ir Uftnsi luisu.il <br />ro lhc povisi.N of c Cooto.i.cs Liccnsd L,w (Chrpr$ 9. Conftftin8 wilh Sccliotr ?0OO of Division 3 of rhc Burincst and <br />Pofcssi.os Cod.) o, rhrt lEo. slE is.xcn{,t rlErclrom.nd rlE basls forrn rlhgcn.kqrion. A.yvhlitionolse&n7011,5byuy <br />ryplica.r for a pernir subimls rhc slllicant ro a civil pcElr, ol .or mrc rhu five hundrcd doll&s (ttoo), <br />-1. <br />N nwftr or rh€ ptuFrly. d my ery)lolss wnh qds.s 6 tlEt ele ompcB{htr *ill d. llE so.i ad dE *n$c ir ml <br />i eidcd or oficrn fo sb (Se.7ott. Busim$ ed PrDfssi.'B Cod.: Tnc Coftetor'i LieM llP ilo.. ml +ply to d owrcr of <br />rhc Frl.ny shd hildi or inprwd 'lEoc !d prb dm ffh s* him.ll or h.r.laor lhrclsh lns ot her ow..mpbyNs. <br />pDvid.n rhd sch iqmEmm G ml ir cndcd dolTcad to. eL. ll howE l,r hoilding or i,pr@ftln b eld sidth @ )qr <br />of@npldi,tr tlE Owi( BuitL. will hrw 0r burda of pmvin8 thd h. or .he dit mr txild tr iapow 0E pDpcny tu tt. purpoe of <br />-1. <br />6 o*E of rhc p,oFny. sm crctusilely contEcrins wirh licctrcd conreloB ro onndd trE ImrLtr (Sd. ,O44, BrsiEsi <br />$d h!6.sion Cods Thc Cont@rof . Lic.trsc tlv doe. n6t antly lo m owncr ofpropcny{ho build| or idphvcs rhereon. <br />flrd who sntrocrs for such pmixrs *nh ! C.nrr.cto(, lten*d pult@r ro rhc Conradois Uaos hw). <br />-l <br />an.xcmpr !nd.r SRlhn-- B. & P.C. for rhis ra\on. <br />Drre O*n.r <br />WOR(FRS' CIIMPFNSATIoN <br />DECIAMIIAA <br />I hcrcby llfirm under Fn.lry oa pdhry otu of rh. folloqing ddlellions: <br />I rhtr (ixlc. lnr rhc |{rfinnxn.colrh. trork nlr$hi.h rh. plmir n i\{rd <br />_l hsrc a.d sill @inrain work 6 cohpcnsalhn i.suEmc. as r.glncn by SNt ion l?00 of ltc Lih.r Codc. lo, E p.rfo'Ill,c of <br />th. wor* for whi.h rhli pc.mir is ns.d My vorlG6' otr{EDslrion inruEre c8i6 &d Policy numb( aclA)tt td5 <br />oo0l7o2 [11 tz lro Irs <br />-l_lccnily rhat in rhc txfonMnmofrhr wor* fnr whicnihis p.rmi! k hsucd,I \hall nor cnployaorl)cBdn i!dymmmr <br />$ as b hccom subjd ro lhc $okdl oq,cn\ ion bes oac.liaodia, d.8mrhd ifI should b.com su$jEl lo lhc <br />workcr coDpcnsrionpmvi\ion\oaSccri(,.lTmofrhcl-rhtC(xlc,fonhqnhconlply *ilh lhos pn!hions <br />WARNINC: I'(ilurc to $crc rorkcr' compco\lrion co dd shall rubi M mplorr lo sin nul Fnulrts ad <br />civil lincs up lo orc nundrcd thouend dollars ($l(n con ol c.rp.m.rion, &mges oe pmtil.d for lhc <br />D[!LtLtrt <br />I hcrchynllnm undcr l{mlr, or jr.rjury rhrl I u.lien\cd urdcr rnrisnr of wirh Sc.lion 70(xr) of l)ivi\ion.l <br />of lh. ausiffis a.d Polasions Cod., ! my lkcns n in 6iI fore !d <br />B(-cz-i N <br />(ttNs't'RU( t't(,\ t,uNDIN(:,\(itNcl <br />Fnalryofpcrjurylh lh!rc is !connrudiotr lcndins uEcrc, r{, <br />'hc n rfor@no olthc w.rk for,hich lhn IErhi n <br />AftttctNlDEtllEdlla! <br />I lrcrdiy nllnr un q pcr lly or Jsjry otru or rhc n,li,$ inr dcc hrrr ion\: <br />I)c r) l nnr lcrnrirs A\h!{o\ Nor illrrrntrr rtdcral R+r ld $n\ I I irlc ,(). ?an6) <br />Rcquncd l-c(cr.l Ndric hn <br />I Nnily rhot ihc lcdcral ESulorions rcnxxrlrrc nor x|]J'lrcablrro rhi. pml..r <br />_I.cnif, rhdr I hlrt rcad rhk applk.r ion n corer.I lsB ro omply *ir[allciryu&l counry <br />ordinancc( nnd Shrc ljws rclal rurhori2c qtuscihri!cs of rlris Cit, rtrd <br />aborc nrcnrioncd tmpcny for td)r a t3 <br />Final Test <br />irsftd (Scc :1097, Civ. C.), <br />l.ndcr'\ Nimc <br />- <br />I <br />--------T------ <br />tt <br />tt <br />i-