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APPROVALS DATE ID/SIG.COMMENTS OI!NER DUILDER DULCAITA'I]ON
<br />I lErchy rinnr urdcr |cnrlrv oi E-riry rhrr ! anr crcnpr lonr rhc ContrbF- I-Nn{c hf, nr
<br />'h.
<br />tulr wins rcls (sc. ?lr-tl 5
<br />llu\i'rc\r and llolcsn Codc) Ant Ciry or G'udry shi.h rcluncs n tuinn b .oD{rucr. rlr.r- i'np(rc. .nxnnh or rcnlr rtr}
<br />sru.rurc. [i(irr, n\ nsunN..rh.rcquncsrhc{'p]i.rnrlor\u.hEnib,ikrsilird{nr.nr.rrhdltot\hcislic.tr\.dI'trr$rnr
<br />h rhc pn,vi\i,* ,'frlf, (,rnr(ttr s t.i.cns.d LrN lChiflcr 9, aonnncn.i,r8 wirh Src!ion ?fi)o ol Dilnn)n 3 ol rhc Bu!.csr rni,
<br />I'r.rc(rnnr\Cinlc)orlhrih.orshcncxcnDlrhcrcironrindrhctu\i\i,nrhcrlLgcduorPLotr Atrrvnnnti, olSccrio io.ll5byrtry
<br />:'plt li.afr lnr a FnDi[uhjccrs rfu rtplicun( h x .i!il pcnrl(y of nor frnc rh tr livc hu trdrcd d.lhn lS5l[)
<br />Ldt, n. "*w nt,trc nn,r"ny. o, m, cmployftr w h w,ecs s rn n ek ompcndion. *ill &, r,E wo* ,rl rll stuiw n mr
<br />hrc Ld o.otrcEd for $lc (S€.104a. BNiNs and Ptuf.ssions Codc Thc Conterol. Usde hq do$ ml apply lo dn oqM of
<br />lhc ldp.ny elE brilds or inprcB Emn, !t wth dB ieh m* hiN.llor hcs.laor lnmlgh his or her o*r.mployes.
<br />l,hvklcd rh xkh inp'bwnrsEmli ond.d orotrcrd ror sh- Il ho*ffi.ltc hildittS or i'rqNte ii sld sithinoN F!ofonpbrb( rlE OwM Builder wil hlw tE bmhn of lbvin8 tlEl lf, or slE dil ml hriu or itqmt Uie pDpory ftn rtE pElss ol
<br />l. d owncr of rh. tmp.ny, am .rctusitly contrsdins sith liccnrn coir,8l.R to oisdcl rh. FoFtl (Se. 704.1, Budm$
<br />and Eoc*sim Code: Th€ Conrmlor'r Li.cn.c lrw dm. mt lnply ro dn owncr ofpopcny*ho blildr or imProts rhEcon.
<br />nnd *ho co.rocrslor such lmjcch wirh ! Co.hdon, liccnsd l,lFunr ro thc Con!_rciofs Lk.ne tlw).
<br />I rnrcrcnrr uM.r Sc.l
<br />\-/=.
<br />DICI.AAAIOI!
<br />I hfcby r[irn lndo Fnalry of pojury onc of lhc follosi.S dcclffdions:
<br />hlxtr Cud..lir rhc N,li)mrnc..lrhc ro' ( li,r whirh rh. ncflnir i\ i\{'cJ
<br />-l harc and will mainrain worlcs 6np.ns ion iNur.kc. Lr Equird by Sctio.l70Ooflhc Ljbor Cod.,lo, ttr rrcdor@tr€ of
<br />the *o* for enkh rhis
<br />'tmi
<br />ie i$ued. My workca corlxNrion insurmc c@ir !d policy NmlEr 4.i
<br />L^y'eniry rlw in rh. peirorBBc ofrh. wmt rtr whkh rhk pcrmn is kslc<L I shall nor cnuloy N.r r.rsn in any mnnc,
<br />e .s ro 14sm iublrl to lhc sdt6 onpcNdion bws oacllifoni.. a.d agr$ rhtr if I should b.<om subrc€l lo lhc
<br />wo*6.onlf,n{tiontovilio.sofScclionl?00ofthcLnttrCodqIshall.fonhwilh@mplywilhtlEepmvishns..
<br />WARNINC: FliluE ro *de k*es omncnsrhn covcsec ii unlastul. snd si.ll $biel d.ntptoltr lo oinird Fnnla. rnd
<br />civit 6n.s up ro onc hodrd rlsustd dollm (S100.000). i. addirio. lo ltE .ost of coryrcnsslion. <lrm8.s .c pDvH.d lor tn.
<br />Ssrion lm6 of rlE Lsbor Cdc, ir cms d{ rilont' i ler
<br />LTEENSDLCON1IICIAA
<br />DEII,Af,AIIAN
<br />I hcrchyrmrm undcr n{uhy.Ip.rjxry rhd I rn lic,rrn und.r rovisn{ ofChoprcr I (fl,6nttin! sith sc.lion ?m0)olDivisi()n l
<br />of rlr Busincssnnd P.ofcsiorrCodc. anl mr liccns i\ in fu ll io,e and.flitr
<br />Lienscch$: Liccn* Nunbcr:
<br />rl)xslf,t&uaNrllt1tlc-d1i[NLr
<br />I h.rcly rflirm uklur trflrlryof!.rjuryrhur rturc n!connrudi"tr k i'r8rgcn.,ntrrhcPcrfornuk_coilhc*orkr.rehi.hrhhlEnn{is
<br />i\\d.d lscc :l(li)7, Civ C I
<br />AEPI.I!]TNfI}IiCI.A&IIION
<br />I ho$y altimr u ndcr pcnalry olI'lrrrrtonc orrhe n,ll(,*in8 dc.lardnnx:
<br />D.B)lirn Pcrnik \b.dos Norili.arn rcd.ral Rc8ul.tions('lillc 40. l'!no
<br />Rcqun { txircrol Ndiriolinr
<br />l.diry(hJi rhcfcd.mlrcBUlrtion\rcs! nrsusbc(or rcnn'vulrc iorrP,'li.nhlc r' rhis Pmitr.
<br />l+J.cniryrh'( t h,!c,ca,l rhi\ aprlicrrion,r {.rc rhJr rh. Jh,v. irr'om ion i\comcr I {sN k, comrly sirh rll (iry lrd counr,
<br />;rdinrN.\ und Srar. bws cldiry h huildi.s c.n(tudk,n-,i hcrcby iurhorizc rc[crcntdivcs (,flhis Cirylnd Coonry kJ.ms upon rlr
<br />above nEnliomd prcI'.rly for
<br />Amlic r or Ae.nr si8n,arc:;I1B
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rough Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Ranqe
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />Openinos
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.eldr{n >1)
<br />It vt
<br />Meter Helease
<br />FINAL qln l$' I 1.r^",ror(t1)
<br />Notes, Remarks, Etc.I 0\
<br />MECHANICAL-INSPECTOR RECORD
<br />lnstallation
<br />'nzet'tlt
<br />Final Test
<br />,"", DB-t4-r8
<br />Polky Numbcr:-Expircs:
<br />-
<br />o"1", Og-112-lg nr,r-nu(-f7o
<br />t 'dd 3 N!m.
<br />-
<br />,,,",'09'14'lg
<br />tt
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