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MECHANICAL-INSPECTOR HECORD
<br />APPROVALS DATE COMMENTS OWNER NUII-DI:R DEI-CARATION
<br />I hcrchy ritun undcr I[Mhy (, rurjlry rhd I !m cxeDpr li! rhc Conrracro6 Liccn\. lls rtr Ihc rolro*i,r! rcastr (scc.7o.rl 5
<br />B!\ire\s rnd I'.ofcsion G)dc):
<br />^tr,
<br />Ciry or Cl,u , shich rcqun s r ll(nn k, ..tr{nrct. rXcr. nnpnve. d.nynnh or Nt\'n Jn}
<br />qfl(urc, Fi{n r. irs hsu!..c. ilro rcquncsrhc olpli.Mi ror su.h licirnirro Ilc r sisncd srurcnf,fr rhd ficor \hc i\ licrtr\c'i |]trjur -xr lhc pori\iins of dr ('t r,.ntr\ l-i.cn\rd tis rchrptcr 9. C.nnNn.$B wirh S.ctn,n 7({Xr ol Dirnh :r .l rhc l)u\inc$ rnd
<br />Pn,ra$i{,n\ C.d.ror rhar tE or shu i\ crcnU rh.idnm.ftl rhc hrris ntr rhc rlLsd crcnprirn Atrrvtnrri$olScdbnT0rlShy ltr}
<br />rptlL.atrr r(n r J[rdir \lhjccr\ rhc uppl cnnr k, r civil rcM lry oi nor nm rhm tlvc huidrcd dolh\ ( $t(xr ).
<br />-1.
<br />&s osftr of ltc pmF.ry, or f,y cq,lolss wirh *tr8s B rn n $E smncnsarion. {i! & tlE wdt ad d* srE@ ic ml
<br />inlc .d o. oILrcd for slc (56,7014. BusiNis ed Pr.f.$jo.s Codcr Th. Conrftbls Liens LlB d.cs nor aPlly lo M o*nct or
<br />lh. FbFdy wh) hiilds or itr!rctts tLen. &rd who d{4 o.h srl hi6*lror h.relr or ltmlsh nis o, hd ow..mPlorecs,
<br />lnlidcd lhrl slch itrv,rctmntl @ Dl inl.fl(h ororcEt for sL lf, nokE dE l atdin8 s inrmwft i6 Eld wirhinom tw
<br />of.oqlcliotr r osrc. Buili,fi eillh,E (E brdciofprDvirg rhtl tEorshc dn d hiltor inpbE th. tmFny forlt Purposof
<br />-1.
<br />as osmr of lhc ,n'Ilcny. !mcxclusirclr.ont&tins uith licensd conlmroE k,.onnruci rlE t'oicr (St.7cl4. Busm$
<br />ond Etrfsshn Codc: Thc Conl.0.lols Liccns. tiv docs nor stply to an o*nd of[ropcn, who builds or improvcs lhcrcon.
<br />and who onrEcrs for slch lmixk $irn 0 C.nttucro(t licen*d punu!.r lo rhc Conl$clols Licctrs L{*).
<br />-l
<br />dcxcnrt !.d.r S6don- B. & P,C. for ftir rc&io..
<br />Drt.: ovmr
<br />lltBtrE8tiioMllNtA.rMa
<br />DEII.ASAITON
<br />I hcreby ainn, udcr pcnalty of pcrjlry orc ot rhe hllo*i.g ddl{aiions:
<br />l-rhor (ixlL. li)r rlI Nrronhicc rlih. No'k ntr Bhi.h rh. t)rrnir ]{ n\ucd
<br />I haw and will nrainldin work B .ompcnsark,n insuoncc. xs Equirn b, Setion 3?(x) ol l,t trbor Codc. fo, rh. I,.rfrmre of
<br />lhc wtrt aor pnih lhis lr.mil t hsucd. My worlcB comFnslion insuEncc (tricr anj poli., numbcr ml
<br />kh G4 )A4->
<br />lo
<br />l.cnifyrh t in rh. F formN ofrhe work lor rhich lhn pcrmil k iss!ct!. I shlu oor .otkly any ,,.rsn in.ry 'tunmtso asro bccom subict lo rhc ro,tor conrFrsarion hws Dfc.liloni,, and,8r. drl ifl should beom subFct l.lL
<br />worknl conrFnsllion ,rmvhions ofScclioD l7(x).frhc L!h.r Co<tc.l shall. todhwnhompl, *nh tbs povnions.
<br />WARNINCT Flil,rc x, s.uE workcrJ comr.osarion cDvcne! is unkwtul, lnd shall slbixl copk,t r ro aininol I'cMnics and
<br />civil lln.s up ro on. hutu]rcd lhousnd Jollffs ($loo.ffD). in lddirion lo rlt cosr o, coorpc.\lrion. donu8cs as providcd for thc
<br />,:-;/ i
<br />DECLAAA.IIOX
<br />I hcL*hyoriiflnundcrprnrlrlofpcrjuryrhar I xn li.tiqlxidcr pn'visi ol ch(I)rq 9l connmn(ins silh Sccr i,n 7m0) of Divitnr :r
<br />of rh. Busirc\lrM PnrisvorN Codc. d my liccn$ is in lullnmcardcflccr
<br />=/J4
<br />(:oNllallcrllNl,lNDllli-{GElCr
<br />I hcrcb, {ffirm und.r p.nrkrofpcrjuryih,i rhtrc iss$NtNclion lclldnrsu8cncyforlhcpcrfornlmcorrhc wort for whth lhh pcrmir is
<br />tsucd ( sc. 4097. ci!. c )
<br />AITUCANI.DEIIAaATAN
<br />I tEeh,afi uidcr Fnaxy ofF jury orc of rM follosinB dcllrarionr:
<br />Dcni)lirk,n P.flnir$Ash.ios Norinc ion rcdcrrl RCBUL(ionsl'lirlc 40. Pd6)
<br />-Rcquned
<br />llrrcr ol liorific.rioi
<br />-l
<br />.cnif, rhlr |lrc lcdcd rc$Llions ESsdinS sbcslos rcmval m not lrllicabk lo rhh Im.iEl
<br />-l.cnifyrhar
<br />I nlvc rcod rhn rpDlicark,n and iarc rh,r rhc *.v. inrormri(,n iscotrst. ltrgre ro c1rryly *nh trli Ciry 0nd Counry
<br />oniir Ns,nd srd. t2ws rbrins ro buildins coi(d€rioL arn herchyaurh(riz. ict)l.snhrivcs oirfiis Cilyand Counrr ro.nl* uP. [r
<br />lhow nxnrioncd pml,.By for i.Vsrion
<br />Appli.mr or ABcnl Si8mturcl
<br />Pc.nrira nmrc (prinl)
<br />-
<br />A 1 K-
<br />Appliances
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Duct Work
<br />Pre-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 />Openings
<br />lnstallalion
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.//h 'q/l{ ra Yry4 )
<br />Final Test - -l
<br />Meter Helease
<br />FINAL 1/e t'/tc.4 *'3t/
<br />Notes, Remarks, Etc.
<br />tD/stG.
<br />Metal Fire Place
<br />lnsulation
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<br />I
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