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MECHANICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUII-DER DEL(IRATION
<br />I h..c6y rfinm ud.r FElry of pcrjury thar I m ercnpr 6Dn rhe Coirn 106 Limns LiB fo, thc louoyur rcaen tScG 703, .5
<br />Busings lnd Pmfcsion Codc): Any Cn, or Cdnry ehich rcilics a Fmi 16 mn$rud. dlcr, iq,or. dcmlth or q€t lny
<br />sirudm. prior 16 nr L*@m.. at$ r.quiEs UE .ppltst for $cn Fmil lo fih a sisEd slalemnl lhll lE or .lE ir liensd PuMl
<br />ro rlc prclisions of rhc Conrlclort Li.co$n ttw (Chaprel9. Conmrcin8 w n S.clhn ?000 of Division 3 of rhc Busioesr 6,
<br />PNlcsiions Cdc).r rhar lr or sh. h cx.q,l rncE ron and nE ba\is for thc rlkgcd cicn\nion. Any viohrion of Sdion ?031 , by !n,
<br />or,plicsrr lor 0 t'.rmir subj.{rs rlE spllicant lo a ciril t,cd6lty ot tur mrc th.n nvc tundrd dolL.s (t500).
<br />-1.
<br />&i owM of tc nrcFny, or nyrmplolt s wilh wtre* B ln& $t onFnslion, will do rlt wo* od ilE shrrE h ml
<br />inrcrd or ofi@d for sh (Se 7044. Auiirc$ tud Pr$f6siod C.do The Co.kdm'i LicnF &w do.s mI spply lo d owr of
<br />rh. F)p.ny uh. bnildsor in{mB rh.mn. and wno do.s sNh mrt hi clf or hcr*lf or thoush his 6, l'e, owo.mploy.cs,
<br />previdcd rhar such itr{m1ftt s e rct i .'idcd troit td rbr eh. li hosq, rlE hoilding or inplmm is sld *irhin Doe )Er
<br />of(onp,.raotr ft OeBr BuiU.r *ill hlE rh. budcn of Fovins llEr lE or .lE dn ml hrild or in{JEw ilE FDIETy for rlt Io4D* of
<br />-I.
<br />asower.arhc pmFny. oncrclusiv€ly.onlrscling virh lienrd conlrlcl66 ro on(rud rha Fojel (Sc. 7014, Bulirc$
<br />ard l,ron:a on Codc: Thc Conr.,.roCa Liccnsc lj* dfts not trptly ro m owncr of Fropcny *ho l,uilds or idprclcs $.r.on,
<br />rnd who o mcts for suh 0rcj.rls with ! cr.trdcro(, llIfl*d pl,\Mr ro
<br />'h.
<br />conhflor's Ltcn$ L{w).
<br />I rm.rmd undcr Sdrion .B & P.C. fo,lhnrca$n
<br />IIATEf,S:IOMPJNSAfION
<br />DEIIdSAITN
<br />I h.rcby lffirmund6 pcnlh, ol pcrju,y oc of rhc folb*iry d(hbrions
<br />-l
<br />hlvc {d {ill minrsin s Ccnifrarc olcon$ni io Sclf-lmuc aor w.rkcN compcnsalion, e ,rclidcd for b, Selion l70O oa tlts
<br />tnbor Codc. for llE tsfoltrlM€ ollhc sort for which lhc p6mi ii icsucrt.
<br />_l hrvc aod will
<br />'uinrain
<br />*ork.r' comtEnsetion insumncc. !s rcAutcd l,y SNr ion l?00 6f lhc rrb.r Codc. fot lhc Frlmmrcc of
<br />fi. work ad which rhh lcmil is issId. My sorlcG $nFnsrion ins!ruNc dtri.r ard Flhy rumb.r 4
<br />fulicyNunrhcr:-E
<br />_l (nilyrl r i rhctfrntriutr.col lhc sork ntr *hi(hihi\ Nijni is n\ucl- I \tullnor cntrk,y rny ,.rv,n ir snyntnnncr
<br />() i\ Io luonr {rh}cr ki rhc wor kcr\ conlFD\(nrn h*\ of Cxli,nrni , lid lrcd rhdr if l On'uld hccoN srbjccr lo rlru
<br />*b.kcr{.nn{cN i(rtri)rnbnsolS.crion.lT( olrhr lf,txr C{xlc.l shrll.li,nh$irh.orhplysirhthoE pnrni ,r
<br />WARNING Failurc ro s.urc workcis conDcnsalion.ovcogc h lnhsM.hrr lo cdn nrl Fn lrhs and
<br />.ivil lincr u|) ro om nundr.d lnournd dollais (Sloo.fi)o). in dllmscs !s povidcd fin rh.
<br />S(lltri lora ol r r L ri, (irlc. frc,'5rrD(lrno'Ny \
<br />ucl:! DroNr&ll.rcf,
<br />DI'(IABIIION
<br />t hcEhyrlii,nunJ.rp.nrhtoftf,rj1ny rhirI u,lilrtr{d undcr tn)liri utch pr.r9(.onnrn.ir!snhsccri,)iTlxx)).ll)lvi!i,nr.l
<br />ol rhc Burircsotrd Pmrassn.s aln m, [..ne h i. flll lorc. c,Icr.6ur
<br />CIJNSIA!]EITANII'NDINC.IA}:NII
<br />I hcEby rftm undcr pcnrlryorI']rj$y rhal rhd. s r.otr{n.thtr lcndirs r-lcncy ior rht Fraomln c olrhc work tur whi.h Ihis Pcnnil is
<br />i$!cd (S.c..l(r7, Civ C)
<br />ATTLIqINLDIiCIAf,AIION
<br />I lrdy aflim und( p.trrlryolpcrjury onc nlihc follo*irA dcclaralnrns
<br />Dcnn,lirim Pc nir$Aslici.s Noliliclrion FcdcralRcEuhrion\ l'lir!c 40. PM6l
<br />-Rcquircd
<br />Lcrr.. o, Norifi uri,,'
<br />-l
<br />ccnilrlMr rhc fcdcrol rcslhrbns 68,rding lstxstos rcmval arc mr q,plicat tc ro rhn pDjccr
<br />l.cnllylhlll I hlvc r$d rhisapp
<br />ordinan.cs ,nd srarc ljws rcbrinE to I'uild
<br />abovc mnrion d prupcny for
<br />Atpliunr or lrnr SLginru
<br />(
<br />Appliances
<br />Ivletal Fire Place
<br />Evaporative Cooler
<br />Compressor
<br />Misc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rouqh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Ranoe
<br />Type I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />Openinos
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Rouqh Mech.
<br />Final Test
<br />Meter Release
<br />FINAL
<br />Notes, Remarks, Etc.
<br />Furnace
<br />Other
<br />Hood
<br />Above T-Bar
<br />Dal.: O{ncr:
<br />I
<br />I
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