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MECHANICAL.INSPECTOB RECORD
<br />APPROVALS DATE lD/stG.COMMENTS OWNEB BUILDER DELCARATION
<br />I hcrcby !fim und.r p.Elly of pcrjury lhat I m .x.nq ton lh. Contclou Liens Llw for llE lolhwinS rclsn (S.c.70l l J
<br />au.incsr and Prcfcssio. Codc): Any City or Co! y *hkn Eauncs ! tEnit b onsMr dr6. intov.. &mllrh or cpon ey
<br />stddue. prio .6 ir. L*!@.. .l$ rcquils rhc arpli.d lor su.h |trdl ro ,ib ! saged .mlcm lhar lr or slE b lienFd puM.r
<br />ro thr Dnrvisiois ol rlr Conr(rolr Lians.il bp (Chprcr 9. Com'mrcing wirh Sccrion 70m of Division I ol rlE Businc$ and
<br />P,EfcsiioB C.dcl or lhlr t! or chc is.rcnpr rhcrerion ud rhe besis for rhc alh$d .rcnorior. Any violdior of&.ri,n 7031.5 by a.y
<br />lpplic&l for . Fmil subj.rts llr ippliqnl lo 3 civi! p.uliy of rcl m.. rhrn fivc hudEd dolbrs ($50o).
<br />_1. &{ owr otrh. leltdy. or ny cmtlo}rs *nh s.g.s as rnct $lc dnwnsrion. eill & dr qqk ad ln. nndr n mt
<br />inleaLd o.ofc,cd fd sb (Se,?044. BusiBs a.d PtofsioaCo<!s Thc Co 1816r'. Lkr@ llw d@r ml lpply lo s owB oa
<br />rhc Fbltny eho hilds or ir+o6 d.en, un *ho d(E sh w* tirelf ot h.Elf or rlhl8n hit or hd o*n .mpl6rrc!.
<br />lmvn.d rhll such inp,ownls e ml hlodcd orofmd ror sL. ll h.*wi tlE hiildin8 or inpmEmnl t $ld qhftin or Fa
<br />of@aplxio,L tlE OwB Builkr *ill hlr 0r hrdo of Flviit rlEr h. 01 sl* dn er bild o irTiM 0r poFny for ltr purpos of
<br />-1.
<br />!s owrcr of lhc ,mpcly. !m cxclusiv.ly conrraclin8 with li.cnscd .onlracloF lo onslMt lhc ,rnic.l (Scc. t044. Bu\ims
<br />.nd ftohssiin Code lhc Co.keror's Lic.n$ trw docr mr rrplr to !n owrcr ofpmFny sho builds or imFows thcm(
<br />lnd who sflrm.ls for soch lmrEts wirh a Co mclo(O liccnsd putrunr ro rlE Conrraclois UNn* L!v),
<br />I dncxctrrl, xDdcr S..r
<br />IA8EIBII-COIIIINSAIXTN
<br />DEIIASAIIA
<br />I tErcby &til.n ! ndcr pcnalty o I pojury orc of &e follow iog decleodo.s I
<br />Ihrv.rtrdwilliridrhrCcnifi.drcolC.trscirhSclrln\urcn)r*orkr...nr|{n{ri({,r\ Frvnbd tr hy Sccri(r.17(x)ol lhc
<br />hlxn Gnl..lbrrhc t^-nnrnEncc oI lhc {orh t,*hich rh. pcnnir i\ irsuc'l
<br />udi 3id eillDrintain s.rkc '.omp.nsartrn in\urunc., rs mqoncd htSrrn)n.r7(x)ofrhc Lahor(od..lbrthc lcrlo mrcc.l
<br />rd whi.hrhi\ ncnli i( n$.d My wo rkns' .l,.rj ^-n\rr ion in\urni.. .ari.r d F,li.ytrurhcrml
<br />Dnu-.u-r-@-uw7 r
<br />-l
<br />enity rhar in rh. ncrform@ ottr w6,k tor $,i.h thh pcrmn is issrcd.l rh.ll mr crFhyony FMn in {ny mnrcr
<br />s !s l. bcom s!br..r lo rrE sst6r .onp.nsrion hws of Cdiromaa aid s8r rnd if I should tE om subidt to tlt
<br />mrt$ onp.nsri.n pmviio.s of Selion 3Tm of rh. tab.r C.dc, l dEll. Iorlhvilh sht ly silh ll$$ tmvirions..
<br />WARNINC: FailuE lo s.uc *orlcn' .onwnsal ion orcm8c is unhwtul snd shall $bifl an cmploylr !. 6i'ni.tl ltMhis ,rd
<br />cilil fincs u, ro om hudrcd rfiousond dollss (S100.000), in oddilion r. ric.!sr ot.ompcnsdt,n, damgcs.r p..vidcd for rhc
<br />"".,(-=-r( a
<br />Ltg:!s.Etr-l!)r13]l1:ll)tt
<br />D]]II"A.BAIIAN
<br />oi rhc lltr\irr.\\ n(r11 r!\\i,)n\ (in[. rrlryliccnsc i\ in [,] hrcc ra]crlicr
<br />-)d
<br />3--/L,A A-{, d')
<br />CANiIBIETII)NIENI)I!!.ACI'II:I
<br />I herchyrllnDu.dcr rrnlltyolFrluryrhir ltcr. isroagrucli,tr lc nlsllacftyntrlh.tE nnrorc .l rh. {.rk l{tr *hi.h rhir,tmir is
<br />N\u.d (scc 1097. civ c.)
<br />AfILTANLIIIII.AIAIION
<br />I hcirt, .irm undc. p.n0ll, of lErjury onc of lh. followinS {kcl,{alions:
<br />DcnDlilion Pcrnrik-Asb.slos Nolification F€dcrd Rcsul,lions (Tith.lO. Pan6)
<br />-Requirld
<br />tr .rofNo fraion
<br />c.ni,ythd rh.l.d.ral meulrton! ESudrnE rsb.qo! r.'m\Jln i.t.tIl'(ohk ro thr fmFct.
<br />-qtilcn-iry rrrur r uw rcua rr* !p k.rion I sl,|e rhir rh. Dvc i.r'ormrion ii corccr, I dcre lo @oply wirh all cily and coumy
<br />ordinnn(cs lnd Srulc Lrws rclor ins ro buildinsc.nnrdion. md hc rchyrurkxizc,c!rcs.Dhrivcs ofrhn C y lnd Counry ro cnrd upon rh.
<br />(lx,!c mnlii,ncd pmpcny lnr
<br />Atplicanl or AScnt SiSndu
<br />Pcn,ircc nrm (lrinl)l uA9 *,.,K3-/tr
<br />Appliances
<br />Ivletal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. E quipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Rough Ductwork
<br />Vents
<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 />7^rt-16 6e/z .-7 /
<br />Meter Release
<br />FINAL r-2t-/9,/4//'Z2')
<br />Notes, Remarks, Etc.I
<br />O L (Z C*,Jau Dt u w*l.-L lrl>c*+L tra/-&to-kE;1q-tt-lt trz'7,I
<br />Smoke Detectors lnstalled
<br />O)
<br />I
<br />I
<br />i-
<br />i-
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