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MECHANICAL-INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER AU|LDER DELCARATION
<br />I h.rchy lrfrn und.. p.Blry of Frut] rnd I u cxcmp fDn d. Conrrdo Licens L3* fortu folloving @$n (Ss.7011.5
<br />Busin.ss .nd Prcfcsion Codc): Any Cily or Colnly *hich Eqlncs . psnn lo conslflcl, d!d, inuDw. dcmlich or e!& sy
<br />srtu r!rc. lrior h ils iss!8mc. rls fr{uiEs rhc applitur for $.h I'rni lo lih ! signcd srercm rhd lE or s}E h liensn purMnl
<br />r. ttE pmv*io.s of rlE Conr$crols Liccn$d Llv (Ch!t rd 9, Com,mminS *irh Sc.rio. 7000 of Divhidn I ol lh. ausin.$ and
<br />Pmr.ssions Code) or rhlr h. or slr i! cxcnpr iErtiom and rh. tlris fo, Oc .lbgcd .rmplion. Any violalion of S..lion ?0ll.t by lny
<br />aff,licr tor r !.oI sutjclr ln lpplicant lo aLivil p.nallyofml mrc thD fivc nudrcd dolles (5500),
<br />-1.
<br />N owftr of rh. lrotEnr, or my e mtloytes wilh sasci {r rhcir eL @r,Fnslion. wil lh llE wo* ,n ttt slnrle t ml
<br />i.rodcd n ofIcrd aor sL (S6.IX4, aulies and PrDfc.sions Cod.: Thc Contraclds Liensc tlq do6 nor .rrly lo M owner of
<br />rhc ,mrf,ny *ho hiilds or i'qm6 r,t@n. dd wlh .k*r .eh Mrk hin*ll or hcsetf or llmlgh hh 6, h., oen .n:ployNs.
<br />lroviled thli su.h ispmErnr. m mr inldld.n orofcEn brsh.l( hoE4r,llt toildiiS or itprtrmil b$Uwilhin"m )tr
<br />of.onplction, i,f, O*mr Blild.r wiu hrrc tlE buk{ of prcvin8 rrBl h. tr shc dn d bild or inqrDr rhc Flpcny for th Niroe of
<br />_1, usowmr ofrhc nqEny, !n.rclusilrlycodmcrins *irh I icc.\.d .onru.toB
<br />'o
<br />conslruct thc !,ojccr (Sa.70:14. B!:u6\
<br />dd Piofs*bn Codc: Thc Contrlctn s Liccnsc LlR dcs nor aplly lo !nowtur ofpropcry who build{ or inprov.s rh.r.on.
<br />ond sfio conrncls aor slch pmj.ds snh a Conrndons) lienscd purxulnr io lhc Coflr..lols Lhcns trw).
<br />I lncrcmDt unds Sdnn .B & PC.lo,rhirra.on
<br />1lOf,f,l:f,[.(;0lltENS/III0N
<br />DECIAXAIION
<br />I h.tubyrlilrn und$ p.nrlry.rlr jury onc olrhc nnbwirc dcchrlriotrs:
<br />I hdv.d sillnhinriir r Ccn il'{!rc of Cotrsnr lo Sclalnsur.l'or rorkcs .omncn\ulion- a\ Iln)lidcd lor hySeriml70oolrlrc
<br />lnhrr Codc,l.rrfic pcrfornun.. ofrh. w.rk for whi.h rhol.nn i\ h\ucd.
<br />ZJ-bJrr rnd (,ll hnr nworlcG (o.rlt{n\rrnn in rJnce-rs rcquircd t'yScrrn,n:1700 orrhc bktr Codc. for lhc pctli,nan(c ol
<br />tcrmir is ksu.n. Myworks comtcn$ion insu6*c.ario ud Fric, numb.r m:
<br />t1 12 '1 lll
<br />-lccnitythrr
<br />inlhc pcrfornrncc oalhc$ork tor whichrhisrcrmir k nsucd.l rhnlln r cmploylnyp.re. in anymlnrcr
<br />$ as ro tEcnm subjccr Io rhe workc^' .odFnsarion hws or Clliromii. !d .8m lh0l if I should h(rom slhlccr io rh.
<br />*orlc*.!ry,cnsrionnovhionsofSflion,lT00.tlhcl-arrrCod..lshrJl.fonhviltsryly*ithlho$provnionr.
<br />WARNING: Failurc ro surc vortcn'compcnsotion covcruBc is unlustul. and shrll subj(r e oflortr lo ftiminal Fruhics lnd
<br />civil nncs up to onc hulldEt lhous0d dolhn (Sl$-mO), in ro rhc.osr otconnc.sarion. drroecs ,s providcd for lh.
<br />S..riotr:076 ofllE L$or Codc, itrrcrc( nnd nrlonEy s
<br />o"r",L,f -L1Lf, ,- epprr..r,
<br />DES.6N{IIAN
<br />I hcrchya0nrn uMc! l].nallyotpcrrlry rhnr I rh licna{ ondc! Eovisio. .r chdp'$ 9 (.onmr..inB nith Sedbn ?(x[! "r rhi.i." r
<br />or rhc ausnrsnnd PrufcsstunsCodc. and nryli.cn$ is ir tull tn(r ml rnacr
<br />70L{4lL{
<br />o*", I I
<br />,eniryrhdrhcfcdcmlrcBu,:rionsrcgddnrBostEsrorrcmvalarcmrlpplic,lcrorhhpoicd
<br />-l.cnily
<br />rhd I luvc rcld rhis aptlhortun anl sdrc rhar rh. !h.w ioforNlio. iscorNt.l a8B rommllyqirhall Ciry a.d Counry
<br />mdinanccs and Sr0rc tiws rchring robuildins consmcrion. rd hcEt y aurbrnc rrc{llliiws oarhis Cnyand Coonl, k, cnrd uFrn rhc
<br />dovc,rc.dorcd pmp.ny for insn clio. purln$
<br />Ap/rrnr or Asr r s,8ndutu:
<br />P.nnne oue (rifl ):-
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Ouct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rouqh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Ranqe
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Fire Damper
<br />Openings
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.
<br />Final Test
<br />Meler Release
<br />FINAL l'21<l/9 -r 6e)
<br />Notes, Remarks, Etc.u(
<br />APPROVALS
<br />Drle: Orn.r:-
<br />IQXSIAIJCIIONIEBUTG-&CEN1;}
<br />Iturcbylmrnurdcr pc.llry or Frjury rh3r rhcr i\rconsrtucrioi LidnEr8c.cyrrr rhc N muncc ol thc *ol& r{r shi.h rlrn Nnnir h
<br />i\sucd 1S...1097, Civ C.)t,nn'\Nnr
<br />lrnd.is Addn\\
<br />-
<br />,rppr.rcini urti anliiiw
<br />I lrrhy rfllrm u.dcr pctrdlly oiJ,.rjry oN ollhc lollowinB dcclararions:
<br />DcnrlirnnrPcrnriN AsbcnosNoriri.nrbnFcdcrrl Rclnhrion\('lirlc40. Pan6)
<br />-R.quitcd
<br />l-c[c. o{ Norili.drbn
<br />Grease Duct
<br />lnstallation
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