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MECHANICAL.INSPECTOR RECORD <br />APPROVALS DATE rD/srG.OWNER BUILDER DDI,CARATION <br />I h@by affim u.do pclrlly ofrdjury lllll I @ q@pl 6Dn ltc co racroE Li(t@ t w for lhc bllo{iig @$n (Se,7011.5 <br />Buin6s ed Prolq3ioD Code)r Any Cily or Couly which requirc . dmit lo .oBtrucl, dl6, inprcvq d.nolish or Epoir ey <br />3trucluc. Fior lo it3 isude. !&o ..q!irB thc arplicd for such pqmi lo lil. . srgn.d ndtul lhd hc or 3h. ! lico5.d plNul <br />Io rhc provkio* of {E Co tulol3 Liccn .d ke (Chopr6 9. ComDc.cire wilh Sdtion 7000 of Div ion 3 of lh. BBin* ed <br />PFf.sioc Codc) or rl[t h. o sn t.xdpl {6.fron Dd th. b6ie ror ttc tlk3cd.xddioi. An, liohion ofs.dion 7011.5 by tny <br />applicEt for a pcEir sb.iels thc s@licer b . .ivit porlty of tror hoE rhd fiv. hudtcd dou$ (S500). <br />I. s oMd ofrhc proFny, or oy cmdor@ wth qas6 s rh.i! elc compoBalion. will & $. uqt( exl lh. $r6tdc b ml <br />intaxLd or oll6.d for selc (Sd 7044, Aci.6 6d P.ofBios Codc] Th. Cot mcloas Licm. L{w do6 el ryPly lo & os@ of <br />rh.FrFry who hil& or in4rov6 rlE6a &d who do6 scn s* hitu.ll or h@ltor rheu8h hi! or 16 oM orployG, <br />Fovidcd lhal such imForG@l3 e @r itllod.d or otra.d fo. slq I( lhw.E. tlE hildiqs or iry.oEEn b $ld trtbo onc,@ <br />ofcotoplaio( dE Ownq tuilda will hsv. th. tund ofFoviq rhd h. o! $. dd iol h d or nrprDw ti. FoFly forrr FtPosof <br />-, I, 6 oqtr oflhc propsly. d sclusi!.!, coiradi.g uih licaE d coflracroE lo corelrucl ln Frj..r {56. ?04.4. Bsse <br />ard PBftsion Cod.r Tn. CoDa&lols Lic.ns Lsw do6 mr spply ro e own6 olpopcny who buildr or improlB thd6n. <br />a.d who @hricts fo. slch Foj6l3 snh a Co.t!cro(!) lkd..d piEuln ro rh. contractc s Lic6s kv) <br />-l <br />d ercnp ord.r sftlion-. B, & P C for rhh r.Mn. <br />D.tc: Or..r: <br />!q86E85:COM!EN!ATA! <br />DECLARATIOII <br />I ha.t, 6lIm undd Fraly ofpqjury oic ofih. followi.r dccla.lioG; <br />I have ud *ill <br />'nainrain <br />a Ce.lific.l. ofconsmr ro Sctl- lBurc fo! rvorkC .onptu,lion, d p@lidcd lor by Setion U00 o f llE <br />I h.vc and $ill mrintain sork6 comp.Nalior iNuBnc4 a by sation 3700 otrhc Lrbo. Cod.. hr lhc p6folr@a of <br />$. work aor whict lhie p.mil <br />I c.diry rhd in rh. pafomnc. of tlE eo* for which rhir Fait iJ issu.d. I shall .or loy &t psen iD ey msnd <br />$ ri ro heoEc s!bj..1 r rh. M d .omp.nerion li$ oacaliiomir. ud <br />sorl6' conpoerion provGioB of Sstiotr l?00 of th. L,bo! Code I slallt <br />WARNINCT Failu.. to sue wort6' comp.elion .ov.6g. is d 6p!o,6 ro ominal lEn llis md <br />lho@.d doll6 {1100.000 <br />T <br />io!. driyls ! a p'ovid.d ror tn <br />0 <br />!]c!rsE!!oNM(l!a <br />DItCIABAI(I! <br />I hdcby amm .ndd po6hy of F,jury lhol I m lic.Nal undd Fovision of chapla 9 (onodcios witt Sdio. 7000) of Division l <br />ol rh. BBinN Md Ploi*sioB Cod.. ad ny li.@ b h tuU fo@ od.rat.(>r6:- <br />CONSTRTJCTION I FNDINC AGTNCV <br />rhe b r codtudion kndins tred) tor rlr F folr1Ma of lh. wort for \rr ch rhi! Fhi bI h6.br rfl@ @d!. Fi.lty.fFjury lhrl <br />i$!.d (Sd- 309?. Civ, C.). <br />AIILrcAtrTDICIAAAUO! <br />I holbyEftnurd6 Fnalryolpdrury onc ofrn aollo$ing &.laE(ions: <br />D.oolirion P@iG-Arb€ros Norilic.rio. F.dral R.Suhlion! (Tnt 40, Pan6) <br />R.q!ired L.rts olNolifrcation <br />1^,, <br />ii thrt lhc f.ddal rerulalioB Es6dins dbBlos ,"0*'*, ly--- <br />I alte ro omply wirh all Ciryandrh'l I hr!. cad rhis applic.rio. <br />ordinflnc.s and Slale l,Nseldioslo .Lrlkm,. tpr6c artr Ls olrhh Cir! and <br />aborc ncnlioned prcp.ny for <br />0 <br />t0 , <br />Appliances <br />Metal Fire Place <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 Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech.1 q(s '4144 <br />Meter Release <br />(42)FINAL ),ilt\t't t <br />Remarks :@w l'o of i\a\cl44hl .J <br />COMMENTS <br />Lrbor Cod., for lh. FaomMc. of ih. wort aor whicn lh. pmit k issu.d. <br />lnsulation <br />lnstallation <br />Final Test <br />Etc.