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MECHANICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hercb, sftirn urdc, p.nally of Fdury rhot I m cxchpl frcm lh. C.nlrrctoN Liccn* Llw to. fic followin8 tcasr {Scl ?O3l 5
<br />SNincss md Prof.sion Cod.): Any Ciry or Cou y which Equircs c Imn lo 6nsld.L !116. imgrolc. &mlhh or Gpait ey
<br />srmrurc Fior ro ns kslame. ,ls EqliEs rhc spplh,ir for sxh Fmir ro fih a sigmd .rd.Bnl thlr lE or dE h licco$d t)UN.iI
<br />lo $e pNvhioni of rlE Conlrcctols Liccn*d L.q (Chanlq 9. ComrcinS wilh Sftliotr 7000 of Division 3 ol tlrc Businc* Nnd
<br />Pmf$sions Codc) orltul hc or ehc is cxcflPt lheftom&d rhc hLiis for thc lllcsed crcmprion Any viohlion of Sdioo 7031.5 byany
<br />opplicanl for ! pcmir bicrs rh. .rplicrnl to ! civil pcMlly of ml turc rhin livc hundt d doll6 (5500)
<br />-1.
<br />as owmr oa rhc IrctEny. o, ny c.nploys wilh w08cs as lhct $lc onl,cn'alio.. will do ltf, vst uld lh. smlrlw is ml
<br />inrcnd.d or o,Icrcd fo, el. {56.7044, Busimss ,nd Ptufcsions Code: Thc C.nrmclols Liccn$ Llw does nol lpPly ro !n o*i4 ot
<br />ihc Ftrpcny who tdlds or inr,m6 dE6n. dd sho de. sh m* himlf or h€rclf or lhough hir q h.r own cmploret
<br />,myiLd rhd iuch in{meG.B e mt id.idd tr ofidql rm sb. li how6. rlE hildinS or itrgmwnEnl is sld *nhin om }sr
<br />olonplcrbn. rlE Owmr BuiILr oill h,k tlE b{nkn olpmving $d lE or nE dii ml lnad ot inprcw 0E FDFny tm tlE purpoc of
<br />-1.
<br />s own6 of rfic l,^rpcny, oocxclusivcly cootr.clins silh liccnrcdconrr!.i.rro s.sdcr lhc poid (S* 7(N.a ausNsi
<br />and Pt)lssircodc Th. Conlmclor's Liccnsc Llw d@s nor lptly rd an orncr of [npcn y sho buildr ot imtrovcs thcten
<br />lnd who conrEcrs for rlch 06j.ck wi$ , Conhcions) licn$d punu.r ro rh. cont0cbls Liue li*).
<br />-l
<br />amcxchfl undc, Sccr
<br />l),le: O*mr:
<br />SOB8If,IIj;AMTENSAIIO!
<br />OECLAEAIIQ!
<br />I hcEby urtrm lnder pcnalty dr pcjury orc of thc follosing dela"llions:
<br />lhrvc0rxlsillmrinlainrCeniaEarcofConsc bSclf-ltrsDrclnr*orkc(omP.d{diotr.nsf)rirlcdforhyScctn,n.lTmolrhc
<br />Irtxf Cudc. nr rhc pcnirrnrncc oarhc *ork lor vhi.h rhc Fnnir N issucJ.
<br />-l ll!rc !fld *ill tuinhin sortmt con{Ens0rion insErc, ss rcquncd lry Seiion 3?m ol llE Lrboi Codc. lot lh. FrfolrlMc of
<br />lhc wrt for vni:h rhh lErnn Li ilsrd. My wo.kds' oqrn$lhn inMftc .mi.. {d policy numb.r @:
<br />Poli.yNudb.E ExpiEs
<br />-l
<br />ccrrifr rhur in rhc lledomlmc.fthc vork ior qhich lhn F$nir h h{ucd, I shtrll tr,I cmployany pcen
<br />'n
<br />rny n'anN,
<br />$ as!d h..om sub.,ccr ro lhc wortcn clnt4n{tion bes ofcnlirorni0. snd a8rcc thot if I shJlH it om subicl lo llr
<br />workss osp.nsrion pmvilions or Sccrion l?00 ol rlE tf,hor Cod.. l sh.ll. fnlhlirh snply qilh il[s Prevhions.
<br />WARNINC frilurc k' $curc workcr( conU{n\Jrion ll slbiNr an cnlllotcr k, oi[iorl Fuxac ,nd
<br />cilil lincs ut io onc hu rcd tholssnd dolld\ (tlfl).fix)
<br />sftrio. 1076 ol rh. titn Cidc, inrcrc{ and aflomy * fes.
<br />.onD.nsarion. daroses ss proridcd tbr thc
<br />o*", -?-?- ( 7 nrru*,,,
<br />IhcEby,lItr6u.dcryxnrllyoflcrjuryfilrI@lictr d undr pmvtion of ClEprd 9 (d,nffimirg wilh Scdion TlnOJ oaDivisi.n l
<br />ol r lrl\ n!$ xr'lllfl.\\rr\( rrl.. xkln'v lr. N n i',
<br />,*.,1 -3 -\
<br />I h.rh, nrtu UDdcr lEn{llyofDcrjlryrh, rhcn is r.u'{ru.ri r
<br />krucd rscc :l(D?. Civ C ).
<br />.p.n.y for rhc p..lomuncc oi lhc sork lo. which rhis P€nnit ^
<br />AIETCANI.DECLABAII9tr
<br />I hcr$, linnuMcr Fnnlryol pcrjury om orrhc followi.S dcclarllions
<br />Dcml nnr Pcrmik A\tlt(os N.rin.lrion lcdcral Rc8ulnl ion\ fr b 4n, Pad6l
<br />-Rcqutcd
<br />lrlr.r ol Noiif{rtiotr
<br />-l
<br />ccnify $a1 rh. fcdcEr r.8lhlions EBEding lsh.sloi tomvil e nor otplk blc lo lhis pbixr
<br />-l
<br />ccnifr rhlI I ftavc @d rhh abovc infomrin is.orccl I llgrcc ro conDly wirh allCiryand Counl,
<br />ordinan.c\ ind Sraic LiBs Ehling h.rcbyauthori?e rqv.snrarircs oflhh C'tyond Couni, k, cnlcr q{n rhc
<br />,,,",1'" - l0
<br />(o
<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 Ranoe
<br />Hood
<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 />Rouqh Mech.-9019
<br />Meter Release
<br />FINAL tr(t I u^d.qfir/
<br />Notes, Remarks, Etc.
<br />Other
<br />Final Test
<br />t
<br />knd.i\llnE
<br />-
<br />db.vc mmiomd prelcny for
<br />I
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