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MECHANICAL.INSPECTOR RECOHD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER trUILDER DELOIRATION <br />I hcrctry .mid undcr F.a[y oi pcru.y $d I m cxcn 6on rtc Conba.lou Li.cns rjv aor rhc followinS Easn (S(.7o31.5 <br />Busiflc$ Bnd Poitssion Codc): Any Cily or Counly whi€n Equn s . pcmil lo clisltucl. altti inpro!.. dcmlhh or qEn 3ny <br />sltucruc. prtu ro irs iss!M., aho Eqlircs tlE lppltet for slch !.ml ro filc a signcd slaLm.i thd lx o,3& is lie.*n purucnl <br />lo lhc pmvisions of r Conlrccln s Liccnkd trs (ChrlLr 9. Conmming whh Scclion 7m0 of Division I of lhc Busimss ond <br />Prcfcssiors Codc) or rh lE or shc is q.n{,t rhcEiiom ad tne barn for rlr rllc8ld crq,rion. Any liolarion of Sdrion 7011.5 b, any <br />opplka.t for a pem subjcts rhc aptlic. ro r civil I'cmhy of nor mrc rhan lir hundr.d dolldr ($50O). <br />-1. <br />s owmr oarh. Irlpcny. tr my cmplortrs {irh *!gcs a rh.E sk orp.nsdion. *iI do Ih. wlt ed tlE sfirciE b mr <br />i eid€d or ofrcrcd lor sL (Sd.r044. Busi*ss ud Prolcsbtu Codc: Tnc Colnrelor's Liccnc tlw d@s mt qply lo e owffi ol <br />rrE Fop.ny *ho hild. or inprDB E6tr Md who dc ffh s* hituclf or lEBrf or rimu8h hi or lE o*r chDloyc.s. <br />pbvidcd rhi( such inpokc.s m et irt n&d or onc,*d for sb. lt howei tlE huildnl8 or inpbwmnr is $ld within om )@r <br />of@trOlcrion $e Oei6 Blil&r eill hrw rhc h!&n ofrmving Oar lE or shc dil nor t ild 6r inprew 0E pblEry for dr plrFs of <br />l. asowrcrofrhe I,orrcdy, amci.hrihlyd 6dins *ir! lieo*d conrrdor ro.dniMr rh. pmlyr isf.7ol4. Busns <br />!n! hoEssiotr Codc: The Conrractol. Liccn* l-!w docs n.t olplyio an ownc. ofproFny sho blildr o, inp,ovca rhcEon, <br />d who (nrturi for rlch Imjftls wnh a co n ro(o licenscd tu6@r ro rhc ConrR.locs Licc.sc tls) <br />-l <br />aocxcmfl !d.r Setion- B. & P.c. forrhn l.en <br />Lxl0 r)rn.r <br />!A8f,E8E:C!IMIESAIIqN <br />IECII8AIITN <br />t hcrcby irtrn lndo p.nqh, of rdjury one of fie aollowinE d(larfions: <br />-l <br />narc !d will dinr.in a C.nifaor. of ConFir ro S.lf-lnsE fm *dt6s oqrtudioi. er Fuihd for b, Sdtaor l7{l0 of dr <br />tlh(r Cod.. fo, lhc FrfolM. of lhc mi( for which lh. Fmir ii i!su.d. <br />_l hovc lnd aill Dainrain workcrs cohpcnsatn'n insunncc. !s rcquircd b, Setion :17fl) .f rh. tiho. Codc. for thc pcrftrMmc of <br />rhc so {or *nich rhh p(mrit is i{rkd. My $orkcn compcnsrioi i.sldna cldcr d l6lhy ouobc, m: <br />lrs ,4te-' -;" <br />'t ttt t.|74 <br />-l <br />eniti ${ in th. F.formnc. ofthc worl lor which $is p.rni k i$!cd.l shlll nol cmploy an, FRon in lny mnM <br />s N ro tEnm slbrcl b rn porth otr'pcrsrion has ofclliaomio. dnd .aB lhd il I ihould b..om subjer ro tlE <br />mrtctr' compcnsorion polnioN of Sdion l?00 of llE t bor Codc. I dEll. fonhqilh odrly eilh llte povirhn... <br />WARNINCT Failurc lo s.tric w6rkc^ 6n .nsarion.ohagc ir onlDsrul. .rd sh l subjcd m cnrhrr ro siminol Fnlllics and <br />.ivil nns up ro oN hundrcd (hournd dollds ($l{D,I{,$). in a.tdiri.n ro r tun, damgcs N prolidcd for lhe <br />Setio. 1076 ollhc Lr!.r C.da inr.r.q Md rrrrmy\ les <br />,rn, ?/Z .,-hv * <br />UCEIIEDJONI8ACIOB <br />DEILAEd.IIAN <br />I hcEhy affirm unrlcr pcnalty ol !'crjury thar I am licensn undcr pmvnion otCh.rlq9 (conrmmios wirh Sdlin Tlxlo) ofDivi\ nl <br />ol rhc Ausircs Md P$fcs(ions Codc. ffd my liccnsc is ii full foMnd cifcct. <br />i""n." Nuu,t ,, <br />r /a 5 <br />coNsrxucrllNrDlll$rc-acfNlr <br />I hcrcby a,ftmnnncr FmltyolFrjuryrhol lhsc n o c.n(nrrion lcndins aaen.y rhr lhc psforroncc olrhc sorr lor $hi(h rhn Fnni' i\ <br />isu.d (SLr 1097.Civ C ) <br />AIfLIIANLDICLASAIION <br />Iffiylnj undc. pcnrlty olpcrjury orc ollhc follo$inB del!.atio.sl <br />Dcnlnirbn Permih AshcsrosNotific(n,. Fcdcral Rcsola'ionr (Tnt *)- Pd6) <br />Rcquncd bttcr of Norifi cotion <br />l$niryrh,r rlr r.dcrar rclulnrrns rcsddnrB $l. (o\ rc n,v!rd. nor iplli.abL b lhk roJcr <br />C (Ltn'lJrhJrItu'rrn,.lrhtrunnl'rrrrtnrrln.rh. rltrblc inturnurim n.urc.r.Irsr.rro...r yqithallCirya.d(ounry <br />ordi'rnccs rnd Srric l,rw\ rlatin8 h huildin8 con{turrn[ a.d hcrh]nurhori2d rctr.sctrrdivcs ofihis CirynnJ Co!trry k) cnrcr up.tr rlr <br />abotc m ioned Dbtany fo. iBpedion pnrrDs.5, <br />eWtiur, o, a*n S;g^*L=&4 ^., il./tt <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Ivlisc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork <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 />lnstallalion <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release <br />FINAL {a,t/r*iNiS <br />Notes, Remarks, Etc. <br />-) <br />^,, tlzzlr ? coor*ror F <br />- <br />I <br />------r----- <br />=