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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUIt-I)!]R DT]LCARA ION
<br />I hcruhy rflirn u dcr rcnohy oa ncrjury rhar l dr cr. lt li.'n rl[ Cu rrron l.kcn\c L!tr nrrhc followi.S Bu$n lscc?o:ll5
<br />Busnrs\ rtrd l'rot ssn,n C,rdc) Atr! airy or counry which ,cqutc\ r F-rinn b c.n{d.r. rl'cr, iurr^q {L'mli\h or rc,)an nny
<br />(tucro'.. Ilritrn, ir\ nsudncc. al$ rcquncslhc |Pplicror li)r u.h pcfl irk,lilc r siAncd srarcnEnr rh"r h.or $c h liccnscd Pursulnl
<br />ro rhc provi\n,ns ol rtr Conkr.rtr-r Li.etr{d tr* lChlltrcr 9. On.',r.i.i'rB wirh Sccri('n T(xXJ ol Di!isi{,n I of rh. Busirt.s ind
<br />Phrcsn)n\ cld. r .r rhrr tE or shc is cxc rrr rh.rclro'rand rhc hr\il ntr rhc nlkS.d cxcmnriotr Anyvitrtrnf.l Sccri('nrl)]l5 hyrny
<br />rfDli.dnr l(tr.p(irnil \uhjcrr!rhc rpPlicar n, !crvrlt,cnrhyolm! mrcrhrn r'ivc h!idred dollrn ($50Oi.
<br />\-it* ^, ^, , '* ,""""!. ,tr my.nnhry(r. tr h tr rlcs,N ihcn olc c.'nN srrion. willdo Ihc Bolk Nr rhc {r-rm \ rn
<br />.'\l,a "' ,, n-",1 r" 't r s,..?trr. tlu\i"c$ rd tt' 'li$nnr Co c Thc (1trlticrri l-iccn{ Iiw docs nor .pltly h rn o$ncr oI
<br />th.pn,r y \ l.o h'ikl\ or nq,n)!ts rlf,dll and u'h. d.c\ \sh { od hnnsclf or lrrsll or rhrcugh his or h$ nwtr cnrpl(iycc\.
<br />pm! id.!l ihd \urh inlnrvcNnr uc nor inrcndd or orlLr.n f(n !,lr tl tDwcwr. rlB hu itli4 or itrSnnM.nr t ekl wirhin o c yt,tr
<br />oiconlPhrion. rhcOsN! Buildq tr,llh!\rrh. htrdcnorpmvirSrh r hcorthc did 't htrild or nnfmvc rhc rml{ny n rhcrury'tol
<br />l.nsowmroirhcpopcnr. 'nci.lu\ivcly.onttrirrtsirhli...scdcoDlrr.thro.on{ntrrhcnr.jc.l(S*.' 70'l.l Bulirtcts
<br />u'rd,bll\\i Codc: ThcCotrhct,tr\ Li.cnr l.asdo.\ nor rpflrk) .*ncrolpn,Ptnysh(,buildsoritrrhvc\llrcrcon.
<br />.nd s,ho contra.rst, !u.h nn,F.rs sirh r co.rfl.tu(, lic.trscd pur\ud n,ihccuntricrDis l-iccnsc t!!r
<br />-I s o,\
<br />\
<br />I hcrcby !finm undcr Fnalryotp.rjuryonc ofth.lollowu dcchBtn,ns:
<br />-l
<br />harc dd *ill minlrin ! Ccrtifrcatc ofconEfll k, SclHtrsurc lot workEC otrp.n$lk'n. &r povid.d lor by Sdlion l7O0 ot tlE
<br />Lshar Code forlhc lEforllMe of lt *ml aor whicn E,*rmil b issucd.
<br />-l
<br />hlvc and will mainlain wdlcs cohp€nelaon i.wN, es '!q!iEn by Setion 3700 olrlE l4or Cod.. tor rhc IsfolMc of
<br />lh. wt ,or whicfi lhis t mi ii i<,&d. My so.t 6 codlpc.sdbtr iN@c .,rhr $d Plty nuhbct el
<br />Poli.l Nu nt.r:-t{ltc
<br />(!T?!r,ry rhlr in
<br />'hc
<br />pc,rorMncc .r rh. work ror which rnis p6mir is i$o.d. I shelt nor eoploy any pcr$. iI any nq*r
<br />s a\tglcom tuhj(t h rhc ao*d!'omFnsrion lo*s or cdiromh. md l8R thor irl shorB ha.@ subiNr ro rlE
<br />worlci'onqEnsrio.I,hvilionsofSc.lior3T00oflheLltorCodc,lshtlLfodhwnhdnplywilhllsspm,bio.s..
<br />WAf,NING: F.ilurc lo KW wo cn .onr.nrdion dtrcm8c is u.Lwtul. md slt.ll slbj<l an cnployer lo oimiMl pcMxi.s,trd
<br />.ivil tlncs !p lo om hundEn lholsnd doll&r (Slm,(x)O), in oddition lo lhc corl of.omp€nstlion, dutrE8cs as Pmvid.d for lhc
<br />il5ilEqtr,icT
<br />IIDI;I.A8.AITO!
<br />I hcEhy dllirnund.r pcixxyol p.rjury rh0t I an liccntn undcr pr)vi\ion ofCh:lPter 9 (conuEncins *nh sccri,'n Ttl(()) .i Dn i\irn' .l
<br />ol rhc Busims{.nd Pmicssions Cod.. url mylicctrs is h fullnra.fricflNr
<br />(onl.ncl.r
<br />II)NSI&ICIIIINIENDINC.AIjEN1;I
<br />I hcrcby omnn utrdcr pcnnllyofFrJUry rhnl !hc( n a consirucli(r lcndins as...y for lhe PcrtotnErcc ofrht *urk nr which lhn p.rmir i\
<br />nsucd rSc..:1097. Civ C l.
<br />AIELICANI.DISLAS{ITON
<br />I lEtby oliim uftlcr !'(nalty ol ri.rjury oft of rhc iollowinS d.clurar ions:
<br />l).n{nlion fcrnrir Asb.sr.i Norific.lion Fsdcral RcEularions (Tnb.lo. Pd6)
<br />Rcquircrl Llrtcr ol Norific,ri.n
<br />zl.cnilyrhat rhc fcdcra I csu lnl ions rcaardiq asbe(os rcnmvrlm ml smli4hlc to lhis !mj.{r.
<br />is corcd I rlrm h cory,y *ilh o[ Cnylnd Couoty
<br />r.rcscnrorires ofrhis Ciry dd Cou.tylo cnlcr ulx)n fic
<br />AFlrlicnnl or A8.nl Signafurc:
<br />Appliances
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Bouqh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Ranqe
<br />Type I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />Openinqs
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.
<br />Final Test
<br />Meter Release
<br />FINAL /-3/-/? u tde/o{-a?/)
<br />Notes, Remarks, Etc.
<br />N4etal Fire Place
<br />Other
<br />Hood
<br />Lcndq r N,mc
<br />-
<br />-"b\c*'Y's
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<br />I
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