|
MECHANICAL-INSPECTOR RECORD
<br />ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I h$cby lmrm undcr D.n.lty of IEqury lhal , m crchpl libi llt conrnd6' Lt.M t2, f(r lhe followine rcf,oi (5rt.'r031.,
<br />B$inc$ and Polcsion tuc): Any C y or Colnly *hkh eqlis a Fnil lo con(Ml, .lld. in!rcw. d.mll$ or rcPn any
<br />strucrun. prbr ro ils issuare, als rcqoiB rhe lppli. for sNh Fmi lo 6L ! si8md sldcft lhdlEorshe is liccnsd Pusua
<br />ro rhc F,vilioG oftr Co.rrebls LiarEd tiw (ch4lcr 9. commtuirg *irh Selion ?oilo of Dilishn I of lhe Buin.s ed
<br />Pofcsio6 CodcJ or rhot lE or sh. G crchnl th.rcfroh snd tlt h4\h for rhc rlhScd .x.nplion. Any vinldionolsethn ?031.5 by ony
<br />lppli.anr for a p€mn subj*ri rlE rpplicor ro tr civil p.mxy or nol mE rh5 filc huidr! doll&s (S5m).
<br />-1.
<br />.s owmr otrlE l,mFnn or my crploF.r qiih w,gcs 4\ rh.ir $h co'npcnsalion. sill &, th. ert {nd lh€ {rlE k mt
<br />i'n*H or o,tcrd for elc (Se.7044. Ausim$ and Prcfcsions Codcr Thc Conrachis uen* kw &rs not &!ly $ e owftt oi
<br />rhc pbFiry eho builds or itr{ms rlEen, url who {krs rkh ftd( hinsclf or h.rclf or lhtulgh nis or ho own cmghrcs,
<br />proeidcd rhd strch ihproroFk m no! inr.ndcd or ofisrd lor eh. ll horcvB- lL l4iHi.s ot iqeEBnl ir $U *hhin om ,€d
<br />of coq,lcdon. lhc Owncr Blildcr will harc th. h!d.n ol prc$e rhai lE tr sh. da d hiE or iq,rew 0E tmFry rd ih. purpos or
<br />L asowncrofrhc ImIEny. !neicluriwly.onrrrinB wirh lic.oEd conlrucloF rotonsmcl lhc poict (Sa.1014. Busitu$
<br />od Pmftsion Codc: Th. ComBcior'r Li.cnsc Law des.or lpplylo !no*ncr olpft,P.dy who brilds or irPtovcs ther6n,
<br />and who conrmk for suh Forcrs wirh! ConrBck'ns) lirn*d puN.n o lhc Conlruclols LtcnE Lru),
<br />I .m cx.mpl undcr Se.'l
<br />Drle Oener:
<br />lll8f,E8S:COllrBlAnAN
<br />DEgT.AEAITON
<br />I rErc6y llfirm und.r !,cdhy of Idiury ore of * following &cLnlioro:
<br />lhJvca'!] snlnui dnr Ccniicarcoicl snl t, Scll ltr\ur. in uork.^ ..orNnsdi.n. !\ tolidcd ln hySurritrlr00ofrlt
<br />I rtxn (ixlc. n)r thc |xrtunMn.c ul rhc work lin \rhi.h rhc Ennil i\ i\\ucJ
<br />il h issucd My{ortc6 c.nFn\!rio. insum.c.eicr ufrlpolicy nu'nb.r a.wr
<br />ozc,o
<br />-l
<br />ccniay rh i.rhc p.,formftc ofrh. work lbr which lhis p.rmil is is\t.d, I shallnor cq,lo! any l,cson in any tuoncr
<br />$ as b tE$nE subjel to lhc M,kcF NmpctrBri,n hss orCnlir.nri{ trd +Ec th0r iil should lfcom suhjttr r, rk
<br />soltcrs co,npcnsrion ptuvtions oiSldio.]TIDorrhc uh.r Q)dc.l sh.ll.Ionh'irhcorqrly wirhlhos pmvirions
<br />W RNING: Frilxrc ro {curc qtrkc( c{npcn$rhn
<br />nsurion. damScs .. providcd fur rh.
<br />I ffiy .fiirm undcr Fn.lry of S.riury rhar I m lier*d u.dcr pmvkion of Ch.pld 9 (otlmring with Sclion ?oao) of Division l
<br />of rhc Ausiess ud PDfcsions Co&, en hy lt.E t in tull foE nld.flel,
<br />Lo o3'
<br />I hcrcby rfirm undc. Fnrhyol p.luryrh,l lhcrc is a con(r.rion tndi,g ascn.y ror rhc rdlbrm0ncc oflhc *orl fot shkh rhi\ Frmir is
<br />issuL'd lS.c. 31197, Civ. C.)
<br />A-ttIllA.LLDUeLABrlllllN
<br />lrmbyrnnnu dcr ftrtrrlry ol tcrjury orc or rhe tulhvnrs Jccnrlrnn,\:
<br />Dcnnni(,tr PcirnirrAslEno\ Norifi.rrion Frdrral Rcguhrn s rTirlcltr. hn6)
<br />Rcqunrd I crrcrol Norifi.dridr
<br />-t
<br />ccnify rhd rhc ledcdl rcSuhions ng.rding .sb.slos rcnFlal arc nol aPplkshl. lo lhis lmjecl
<br />lccnifyrhd I lu\r rond rhh dpplication rhc fi,rc inforturi.n is c.,ml.I s8N n,comolywirh allcirydtrd cou.ly
<br />.RliDrn.c\ rtrJ SrJr.l-r$\ fthri'rF t)rrpr.\cnrrrnc\ olrhi\ Cir! rn(l (ouDryti cnr.r trF'n rh.
<br />uhole mnrioncd pmlcny lbr in
<br />lztlr* m Asc
<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 />Rouqh Ductwork
<br />Toilet Room / Clothes Dryer
<br />Residential Ranoe
<br />Other
<br />Hood
<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 />Above T-Bar
<br />Rouqh Mech.
<br />Final Test
<br />Meter Release
<br />FINAL 4/ts/,t &4r\,/n
<br />Notes, Remarks, Etc.t
<br />APPROVALS DATE
<br />Vents
<br />t nd.r's Ndm:
<br />-,,{rof a
<br />I
<br />f-------T------
<br />a--_r_-__ ]
|