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MECHANICAL-INSPECTOR RECORD
<br />APPHOVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrcby lmrm udcr pcMlly (,f p.4ury lfial I m .ren'pl fNr lh. Conlr.lclon Li.ens. kw lor th. followi.8 rc.$n (Se.r031.5
<br />B8incss dd Profcsion Codc): Any Ciry or Couflry which rtuia a F,mir ro onnrud, alr6. improk. dcmliil or r!r& oy
<br />slflcnft. l)nu io h. isrnamc. ,L\o rquircs lhc rpplica.r for skh Fmir lo nh a rigrcn sr .mfl thlt lE or rhe ir lk.tr€d p;rsa
<br />l. lhe Iftvisio.i oa rhe Co tutoas Liccn*d tiw (Cilpicr 9, CommcminS wirh S6rion ?000 of Dilishn I ot rlr. Bw,t ss a.d
<br />Pmf.sions Cod.) or rhar h. or rh. is .r.nFt rlErclrom and rhc boris tor ih. albgcd cxcnpraon. An, vtoLrionotsetbn 7031.5 by ey
<br />applicrnt for ! Fmil subjBts thc applicanl lo a civil pcnalr, or mr mE tha nvc hundEd doues 1$500).
<br />l. ax ouNr oftlE oottny, o, my emnhre.. Dilh wusca !r rhct $k @npcrsll ion. will do rhc wo* ed tE stnllN ic nor
<br />intcrd.n or oltu fo. eL (Se.?044, BuriBs and Prof$sions Cods Th. Conr@rofs Ltcns IlB docs @r amly to an own r of
<br />rhc po!€rly otb ttrilds d inpmts $cmn. ed wfio dc Mh mtt hiDkll or h.tr.lf or thrcugh his or her own €o!lor.s.
<br />provid.d rhir .!ch iqftrftnk e ml iftnd.d n oficEn aor sh. l( howw. dE huildin8 or tr{,tmrEnr is sh wirnin orc )st
<br />or co,tlJlcri6n, ltc OwM auiE6 wiu hoE llE tddcn ol lovin8 lh! tr o. nr did ml boild d inprcw lh. popdy aor th. purpoc of
<br />-1.
<br />I opftr 6f lhc pmFny. 06.rclusiv.ly coorracling sirh liccn*d conr&bN 16 consmcl rh. ,rojcd (56, 7044, Bu\ir$
<br />Md F,Dftishn Codc: Thc Conlr.clols Liccnsc L{w docs nol apDly lo on ownn ofprop.rlywho builds or impmr.s lhcrsn.
<br />ond who @nhll lor su.h pDi.clr wirh { Co.ra.t{{T) lie.cd nGsu rorhcCo turoas Liccns L!w),
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<br />3n cx.mpt lndd S6ion- B. & Pc- for fih esn
<br />WO{l(F{(' COMPf,\SATION
<br />DECI,IBA.IIO!
<br />I h.rcby .firo udc, pcralry oa pcrjury orc o( rhc lolloehB d(lsarions:
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<br />haw ai'd will minllh r CcnifElle of Consnl lo Scli-l.r@ for wortcC .ohpcnsdiotr. !s lmvidcd for by Scfion 3700 of lhc
<br />t hor Codc, rbr lh. !e.for.1l@ of lhc mrt lor shich th. tdnit ir isiucd.
<br />_l hole ond will moinlsin wortcn cohtensalion insuroncc. xs rcquircd bySdio.1700 ollhc tihor Cadc. for lhs lcrformm of
<br />lhc qork for which lhis Frnil is ksn- My workds onpcndion i.sn@. cMtr Drn Flty nunb.r m:
<br />Policy Numhcr lrxttrc:
<br />l..nityrhar in rhe Frlormancc otlte work for which Inn pcrmil t issucn. I shlllnor cnplo, lny Itron in ao, Mn(
<br />so os to h.cotr subicr lo lhc worLcrs ompcnsrhn hws dtCllirndia. rnd aarc. ih,i itI \hould tE onE \ubF.r lo rlr
<br />workctr .omp.nsariotr pmv^ions or sedion lTtD of fi. hlsr Codc, I \nall. tunhwirh .o l],ly wirh rh.e provhions..
<br />WARNING: Foilurc lo scurc workcE s@.nsalion mv.agc is unl.stul. lnd sh.U cnrplorcr lo sinrinoll€noltts 8nd
<br />civil fincs u, lo orc hundE{ lhousnd dollm (llm.ooo). in .ddirion lo tn. o
<br />S<ion 1076 ur'hc L.hI Codc. ikrcn Md
<br />"""*,,/a7//-6 A7'ucErsurcQrtBtgrots
<br />D}]CLAEIIION
<br />I hcEbyaffirmunlcr IEn lyolr.rjurylhsl I an liccnsd undcr pmvhion or chnrld 9 (conmrcin8 wirh ss'ion 7filo)ofDivision l
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<br />CONEIAIC]IONIENDIIIIIiENCT
<br />lhcreby!fttmuldcrFnahyorrcriurylhr'lhdchaoniru.ri,nLnding,Bcftylorlhclnloi,unccoflhcworiforwhichrhisrcrmilis
<br />i$u.d (scc lm7, Ci!. C )
<br />AITIICANLI,IECIABAIIAN
<br />I Imb, onim undu pcn.lly oiFrjuryone olrtu hl[,wii8 dc.lrariois:
<br />Dcn!,lirtun Pcnnir\ AstEsro\ Norificlrion FcdcdlRcBulnti(nr (lirlc 40. Pnnl'r
<br />Rcauncd tltr.r ot Norif&ari,n
<br />I cdify ihd rhc fcdcral ,.gularion4 egddint h6xx rcn,yal lrc nor lpplicablc ro rhi\ p,ojccr
<br />_l ccnifrrhll I nlve rcld rhis lppliclrion lnd sralcth0r lhc
<br />ordinarccs lnd Slaro tiws El.rin8 ro buildinE onsiru.r
<br />6hovc nrcnriomd pfl,Fny for iNFcrionpu
<br />is.oftcr.l a8rfr rocomply*irnlll Ciryad Counry
<br />Epr.*nrdtr.! 6l rhi! Ci!, d4 counry ro cnrd upon rlf,
<br />^,".=/s-s/zr
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Duct Work
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rough Ductwork
<br />Vents
<br />Toilet 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.
<br />Final Test
<br />FINAL 7//o/rw .r't.,6/
<br />Notes, Remarks, Etc.
<br />Pre-lnsulation
<br />Grease Duct
<br />Meter Release
<br />daDl8cs as lrovidcd tu lhc
<br />ol rhc autinc\\ Md PNrcsi.ns Cod.. alxl 6y liccn\c n in lull tuN ad c(ccr
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