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MECHANICAL.INSPECTOR RECOBD
<br />APPROVALS DATE ID/SIG.
<br />Appliances
<br />Ivletal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rouqh Ductwork
<br />Venls ,A\
<br />Toilet Room / Clothes Dryer y-xlv \&:.\0)
<br />Residential Ranqe
<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.
<br />Final Test
<br />Meter Release .4..
<br />FINAL 1-t1-ty 7)
<br />Notes, Remarks, Etc
<br />OWNER BUILDER DELCAR TION
<br />I h.Eby ollrn undcr lEnohy of pcrjury tnd I m cx.mpr amn rhc Co rer6 Li@r* t v fo. ilE lolhwing rten (Se.70J l .J
<br />Busincs ad Prcfcssion Codc): Any Cn, or Counry which rqoi$ a lfn lo $nsifl.l. rlld. irq,mva d.mlht or EI6n lny
<br />srucrurc. priJr ro irs irsuarcc. rko requiEs lnc {ppli.rnr lor such Fmir ro fih ! siSnc{ storcmtrr th hc or shc ir liensed puNor
<br />16 thc pdlirons of rh. Conrerfi ! Lk ned Lrw (Ch!0rc, 9. Cdnmrcing wnh S.crior 7000 of Division I of tlE Businc$ dd
<br />Profcssiom Codc)or rhd h d sn k qempt lhcEfiomod rh. bain for rhe lllcs€d €r.mflion. Ary eiolarion of Serb.70l L5 hy my
<br />aDplka for a pcmn slbixrr rlE lplitic! ro ! civil DctuIy of mr mr rh., nvc hundEn dollar ($50O).
<br />l, rs oqn r oflh. pmFny. or my cmploycrs silh wagcs as lhcir sk oqxrsal ion. will do llE wk 8tn rhc {n&rE b ml
<br />inrcn&d or oficrcd for eh (S8.r044, Businc* ond Pt$fcssiotrs Codc Tnc Coftr.clol. Liene tiw d@s nor spply lo M ovncr or
<br />rhc pn,Fny who boild. or ingmRs tlE6n. ai who &6 sh mrt himscll or tctulf o. rhoush tis or h.r own.q)loy..s.
<br />lrovidcd rh4i *uch ihpmvcftnk m mr inr.ddl or ofr.rd ror $lc. ll rssw. lhc hoilding or irln lmnr is sld *irrlin oft )@
<br />ofeqlcrbn. tlE OwRr Buitld will lEr rlE hd.n o{pmeing !r hc or sh€ dil ior tiild or arplft hc t@Isly for tE p{rF,sof
<br />-l-
<br />osowncrofrhc pmFny. un exchsivcly co racti.s wnh [ccn\cd c.nriacloN ro.onsfl.l rnc pmFcl (Scc. ?Ot4, Businc$
<br />ud Pofc$bn Codd Thc Coorocror's Liccnsc Lrw docs nor {ply ro sn owncr of pmpsty qho builds or imnNvcs ih$con,
<br />!trd who cont€clsfor slch pmicrs *irhr Conlncto(9 liccnsed l{6!ui' ro rh. Conthcroas Li..ns bw)
<br />llmcrcmd udd sdion . B. & Pc. for rhlrrasn.
<br />O*ner:
<br />IIII8f,E8S:TOMEEIAION
<br />PECIAAAIIAN
<br />I herchy atfmundct !.Mlryofpdjuryorc ofrhe folloai.g d<l4 io$:
<br />I hrlc rluillnFidi'riCcniftrtcofco\crr,S.lfln\trrctur\ork.N.oDt'ctldnnr.a'DrovidcdfubySecrion.rTmofrhc
<br />tjtn C{nlc,lhr rhc pcrtuflninc ofrhc sork lnr Ntich lhc F-rmii i\ is\tr.d
<br />_ll vcnddsilln,ni' ni',$orkcri.. rtf,tr\ ri(n ir\uBi.c. r\ rcqurcd hyS..rion l7(Doirhc LihorCodc. lorrhc pc oftMrc ol
<br />rhc sork lo,which rhhIrcrdir i{ i{surd Mywoikc( c(n insu.m.c .aricmnd polily nunhcr uc
<br />-l
<br />ccnifylhar in rhc pcrl'olmncc ot rlE $o.k qhich rhis pcrd n nsucd.l shall nor .nrploy ,.y pcron i"aoy manncr
<br />$, as ro hc.om rubjc.r ki rhc vorkctr'.omp.trs0lion lass.fCrlif.mi\ ond 09re lhll itl should hccont slh,ccr ro rh.
<br />*orkos com,cnerionF)vilions ofSccrion l70oofrhc ljhor Codc,I shall, aonhwilh co'Vly wilh lho$ r,Dnirions..
<br />WARNING tlilurc lo $curc woricn ompcns ion covcasc is unlowt!1. dd shau subi{ m cmploy.r ro ftimi,rl pcmhia and
<br />civil rincs !I ro orc hundrcd lhousand dolh* (tl addition ro lhc .os of co@culion. .kro8cs !s rblijd tor lhc
<br />,,,", u//g
<br />UCEIj.IEDI;ONIBACB}E
<br />DECI3AAIIQN
<br />I h.rhy smnn undcr Fn,lly of Frjlry lh.r I !h lianst lndcr p,ovisi.n ol chlprc s (snmting silh sc.l6n ToOc) of Diririon 3
<br />ol rhc Burin.\\rnd Po,.\\on\Cndc, and nrylEcnsc s
<br />'n
<br />tullr.Rc urd c[cS.L----.,
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<br />ll)IIIBl,leUONlINDt!(irLUN(I
<br />i\\r,llSc.. llr97. Civ C.l
<br />AITLICANLDIS.ABLIIO!
<br />IhcNhyrrlinnurdcr Dcnilly ol pcrjury onc orrhc li,llo*ing dcclunri,n,\:
<br />Dc r,lirnrPcnnir!Adrio\Noiificirh.ld.r(l RcSullliofl\(Tnlc10, I'rnO)
<br />-Rcquncd
<br />kttcrol Nolili. tnr
<br />-l
<br />enifylhd the fcdcElrcsll n,ns Estrdins ashcsxr rumlsl are n,r.plli.abk tu rhis lmicd.
<br />-l.cnify
<br />th,l I havc rc0d lhk aptlicarion and sldrc rh8t lhc ahvc infomarion is.onrr I {!N rooml,lywilh lll Cilyand Counl,
<br />n. srd hcrcby lurhorid Eltrrs.llri&r of rhis Ciry dmt Couniy lo ..'s ulrn rlEdrdi'hrc\ ! d SuIcli*\ rulrr
<br />*svc runrioftd pmp.ny for
<br />Ardiunr o' AscnrsEnrrr 4//rza
<br />E ffntll
<br />COMMENTS
<br />Duct Work
<br />Other
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