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MECHANICAL.INSPECTOR RECOBD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />lvlisc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />Smoke Detectors lnstalled
<br />Rouqh Ductwork
<br />Toilet Room / Clothes Dryer
<br />Residential Ranoe
<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 />Rough Mech.
<br />Final Test
<br />Meter Helease
<br />FINAL c I 1fi,/
<br />Notes, Remarks, Etc t
<br />+
<br />OWNER BUILDER DELCARATION
<br />I h.Eby llrrm unrhr Fn.lry of p.rjlry !h.l I u cx.nrp amm lh€ ConlmloR Lien$ L3! for lhc follo{ing t&$n (S.i,7011 ,5
<br />Busircss sid Prcfc$ion Codc): Any Ciry or Counry *ttn r.iuircr ! Fni ro @nnru.{. !lrr. impove. &mlhh or rclan ony
<br />srerrE, Fior $ irs hill'@. dls requiEs rlE.pplianr tol such tEml ro fib a sigrcd slllcm ind lf, or slr is lk{nBl I'lNanl
<br />ro rhc ptulirions ol rlE Conrtur( s Licn$d Li* (Ch!flcr 9. Conmmins wnh S.cri6n 70OO of Divlrio. I of lhc Busircs lnd
<br />Ptufc$ions Co&) o. rh"l lr or sh. n cx.nq thcnion dd rh. hsG for llr 8lh8cd cxcmprion. Any violalbn ol Scdion 7011 5 ty any
<br />spt,lic! for. p.mil subjelsln applicrnl lo !civilp.nrtyofnol mrcth.n fivc hondEdrlolk s ($500).
<br />-1,
<br />ac ow.( ot rhc ltolcny, 6r oy cnploF.{ *irh elgcs a\ rhct eb .odFnsa,ion. *ix do dr wk nln th. slEtuE k ml
<br />ior.ndLt or oficErl lor sk (Se.704.1. Busircs ond Pmrcsionr Codci Th. Conrmlols Listr* L.w des not lpt ly lo an o*ftt ol
<br />rhc pmp.n, stF build\ o, impmEs rhs6n. un *ho drcs sh s* ninsclf or heelf or fircnCh hk or hf osn .nplor{.s.
<br />fovidcd lh.r ruch imtmvcmnls e ml intendcd or off.rd for sb. lf, lswcver. thc huiuing or itrt Drtu n $ld wirhin oft )rr
<br />ol.omphraotr r Own . Buil&r wiu harc 0h hld.n ofpro{ng rl!! hc or sh. da ml buid or iryrcE lh. pbtEl} fo! lh. pu{ns oa
<br />-1,
<br />asownnoirhc pmFny. !mcxclusivclyconrrucrin8 wirh liccnsd conhclos ro construct rh€ lr,r.tr (Scc.7044. Buci.cs
<br />dd Pr,r6ri,n Codcr Thc Co.r6.ror\ Li.c.r Law docs.nr lpptr ro eown.r orthFny who tuilds or impmvcs thcroi.
<br />lnd who €n'mls io. such pmjec wirh a Coih.ro(sl ticcnscd ,,uNer to rhc Contero/s Lienr ljw).
<br />I ucr.md lndqSerion , A. & P.C.lorthii lwn
<br />wo{l(ERs' coMPLltsAl loN
<br />IECLAAASQN
<br />Ih.rcby ofll n undcr pcndlyolpcrjuryorcoflhc rolhwinS dc.lultbns:
<br />_l luvc ard will @inrlin 0 Ccnilaarc of Cotrc ro S.llln*uE for wortdC smFrslio( rs pmvi.L{ for b, Selion l?00 ot rh.
<br />Litd Cod.. for 'lr !.rformkc of thc mll tor shth rhc poml is irsucd.
<br />_l hlvc andwill minlain wor*cs .ompcnsarion insurincc, as Eqnhd by S.clion l70o of lnc Lrhor Codc. fn thc rcrfomN of
<br />rhc $orl for shicn rhis n rmn ar n\uel. Myqorkch onFnsdrion iosxBrc. c@hr and plicy oumh.r m
<br />,/5-+ r,e.--,. -/T--PolkyNonhd,jxpn !
<br />-l
<br />ccnifylh in lh. Irrformrce of lhc work lor whichlhh pc,rnn is issled.l \hall nor cntloyan,,EBon in,nynrnrct$ u\ lo bcqrnr subjcct to rhc *o*di d,np.nerirn l,*s .r Cllildnid, rnd d8rcc rhrl if I sbould tf,.onf, subjcl lo llE
<br />*oltsa conFnstn'n I'n visioniofSertun ]TOOofrhc LIk, Codc,I shlll, r.nhwilh.omply with ltn* pmvnioN..
<br />WA|INING: F.aluF ro scm *o cr' onFNlhn mw6ge ir unh*tuI. dd shau slbjc{l M orlt,loJEr lo oinifll pcMhi6 ud
<br />rtrrl lincl up r. onc hundrcd rhousod dolls rSloo,UI
<br />S.rri.n lU76ol rh. tih, C.d.. ntcrcn.nd dbmy'{ fe..
<br />^, ' 9'l ?'/ F o,a,-,.!
<br />UCENSDI}I;1}NI3{:IAB
<br />IIECIA&IIION
<br />, hcrh, lirm tr.d$ p.trrllyofpcrjury rhol l.r liccns.tl tr&lcr nmvisifl oiChrtlcr 9 (conrtftiig {irh St.tdr 7fiX)) ol Dnisr,n:1
<br />of ihd Bu$nc$ trtri]Prof.rsbrr Codc, md my ltcnsc is iri trrlftft.n cllt(r.
<br />z,/
<br />c^t*"t*,y -,l)lar,rz ,(
<br />coNsr[J!]r10Nr.!!Dltic-&{irNr.r
<br />I hcrchr.finn undcr |xnlllyofpcrjurylhol lhcrc is a constrclhn Lndins lscncy nr rhc,nfomncc orrh. sorl fot which rhh rctnlil t
<br />h\ucd (Scc .XD7. Civ C )
<br />AITIIIANI.IEII.dSAITA
<br />I hd6, !trm und.r rrcnally of Frjury om of llE folh*ln8 dabdlions:
<br />Dcmlnbn P€mns-Ashcsros Norificarion F.r,e8l R.8!hrion! (Tirl.,lO, Pan6)
<br />-Rcqlircd
<br />kn6 ol Nodfioiio.
<br />_l .cnify rh8r rhc fcrlcral ncllations Ee.iding asbcsros rcmvll @ nol qdkobh ro rhis prcirr
<br />ffi"ily rh0t I h!!c rcnd rhi. ipplicllion dd nrrc rhar rhc atnvc infornurion i*.oml. I r8re ro conrrly with oI Cnyand Colnr,
<br />s and Sratc Llws Ehrins ro huildinE con(rucrion.ord herchy lurhori?c rhis Cirydnd Coutrry ro cnrcr unon rhc
<br />lhow mnrio*d ptul'.ny
<br />Appliclnr tr Ag.nt Si8norr
<br />t -?<4
<br />I e-2?/8
<br />llallft',fi,
<br />lnsulation
<br />Vents
<br />D.r.: Ow.:
<br />*n' ?'2
<br />Ar.r ''.
<br />I
<br />tt
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