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MECHANICAL-INSPECTOR RECORD <br />APPROVALS DATE rD/srG.COMMENTS OWNER BUILDER DEI,CARATION <br />I h6.5y arm uid6 pdahy ofpdju.y rhn I u crmpl non thc Co,lracloB Lt.@ Le lo. tlE fouo$img l€snlaE.?011.5 <br />Bdii* .!d PrclBion Co&): Ary Cily or Counly Bhich rclunB ! pqtn lo @Btrucl, allc. inpovc d.mlish or r@n my <br />srdcrlr.. For 10 il3 ireuN. als rcquiB thc appticer for such panir to 6& a siea.d slal.lMl lhd hc or 3hc s li.rud puBrhnl <br />ro rh. Fovirio6 ofrh! Conrr.ctoas Liffi.d L.N (Cluprd 9. Conmn ing silh S.(iof, 7000 of Diviion I ofdE Bosirs ..d <br />Ptul$iotu Cod.) or rh.t he or shc i! .xmfl rtocfton ed thc b6i! aor thc 0ll.8.d qmflion. Any violaion olsction 701 L5 by .ny <br />lpplie fora pmir subjd13 thc agplic&t lo r civil pc,5tyotnot mocrhM fir. huidtcd dolld (!500). <br />l. s owE of llE FlpEry. or dy dplolG wirh vag6 6 Ocir FL onpc@lior. wil6lh.wo't od te ssu.l@ is nol <br />i'ndd.d orotM for srlc(Sc.?044. Busirs md ProfsioB Cod.: Th. Co radois Lt c Lrw do6 Dol @ply b e oMG of <br />rh. Flpdly who hilds or iEpm€ lh@n. tnd who doe s*h wrt hinslf o. i6.lfor rhmu8t his ot 16 om @plolt€. <br />rmvid.d rhar .uch imFovoril! @ mt htad.d or o&.d lor eL. lf. how.G, E hildiry or i@iwaGn i! eU *'ilhin m td <br />of6&pldir. rhc O*ra B{ilb wil harc U. hnd@ otFoaing tha lE or sl'. dil ml build d itrptot $c FoFt, for fic prpo* of <br />-1. <br />e oma ofrh. pDpsry. @ qcluriv.ly cof,lr,.{in8 wnh Lcosl co ilclof to o.sncl llE Fojel (sc. ?044. Bran6 <br />ad PDfrsion Cod.: Tnc Co.rklor's Lic.6c Llw do6 ,ot .pDly lo m owno of prop.ny eno build! ot inprov6 lhsor <br />&d who .orrEci3 lor $.h Fojeri *ilt ! Codlr.cro(s) licas.d puB@r ro rh. cotnalor's Lkft. ttwl <br />-l <br />m .xempl undd Serion , B & P.C. aor ltis r@$n. <br />WORXERS' COIII?ENSATION <br />DPCI.ASAIIA! <br />I hs.by rfid uidd podtyofFjtly oG oflh fouosiir dcbratioN: <br />-l <br />hav. ald witl mi!t.i! ! C.niE rl. oacolrt ro Sclf-lr$c aor wrlca' odpcddiol! 6 piDlid.d fo. b, Setion ]700 of lh. <br />ttbor codq for . Ffol1l@c of th. @lt fo. lnich lt p<6il ! !tsu.d. <br />I haE ed willnai.llin worr@ comp€Nstion iBurscq, s r.qun.d by Sdion l?00 oalh. Ltbor Codc for thc psfomecc ol <br />rh. work aor whi.h $B p.mn is iss.d. My compoBation insur cc camd dd poli.y ntrmbd dc: <br />I cdrify Ih3t in thc polormncc ofrh.for *hi.h rhis p.ntrir is issued,I shall not €mploy ey Pdson i. any,n n.r <br />e s lo b..omc aubjat ro lh. wrt6' comp.qlion Lws oacalilohia, ed agE lh.| if I ihould b.com. subj6l lo <br />'lEworkqs.onFelionpmvisioNofs.cliorl?00oflh.L,borCrdalsh.ll.fonhwirh@mPlywnnlhospmvicioc.. <br />WARNTNC: Failurc lo su. e.l6'..d!@lio. ov@g. is uhwtul. ed shall subj.tl d dplold 1o cioilrl FEhi6 md <br />cMl fm6 up ro onc hun<!..d rho!$d dollG {1100,000). in addition lo fi€ cost of comp.elion. dma!6 a prcvidcd for LIE <br />serion 1076 oflhc khor codc hl(d @d nloflEy s 16. <br />,^",5/zal6 , {;.> <br />LTCDNSEI) CONTRACTOR <br />DEcldaal]q! <br />I hc.by allm undc Fnahy of p<jury thd I d licd*d lndq provirioi olcharro 9 (comdcin8 wnh S.clion 7000) of Division .l <br />of rh. Busind &d Prcf6ioa Codc, ad my lic.N is h alll ao(e dd cll{1. <br />B Jotc{t1 <br />*-5/2g116- tu-, Cla.-,ow ?o,ze r'l;cq <br />(aNilalclloNl,ElolNc-aqlNcY <br />I haeby affir,n undq poally o f p.rjury ihar lno. i! s co.(ruction LndinS ogdcy for th. p6folr@c. of lh. *orl for $hich lhis Fnh is <br />issu?d (Se.109?, Civ C.). <br /> -8tU( NLDEC! 8At!O! <br />lhi$vifim trrds pemlty olnsiurv oneolrh€ lollos,ns dNldalions: <br />Dennnirion l,ermirs-AsbrsrosNori6carn. r.d(rl Rcstrlahons ('Iirl..r0.l'd6) <br />Rqunsl l!nd of Nori6.dion <br />obovc molioncd pmp.ny lor iN!.dion {/zq/rt <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 I <br />Toilet Room / Clothes Dryer 6-!1'!g t) <br />Residential Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />/,.-,\ <br />FINAL a-1./l v.\r.1r\ <br />-l <br />.diry rhar rhc fcd6.l rcguhtions rcSdding 6b6los rdord are not applicablc lo thi! pojdr <br />- -l cdit, rllal l ha!€ r.ad rhis.ppli.arion ed sr.rclh.l lh..b6!c idlonnotion iscoral.l asre lo coh?ly{nh tll (nya.d Cotrmy <br />odh.nc6a Sralc Larvs rclalins ro building consltucrioh. dd hecbyaurhoriz.r.pr6otalivE olltis Cny dd Counryro drq $.nth. <br />\.NFT?1 <br />Meter Release <br />Notes, Remarks, Etc." \\_/