|
MECHANICAL-INSPECTOB RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCANATON
<br />I h.rcby amrm undd Fnlhy ol psjury rh,r I m.xcmpr fmm the ConlnctoB Lkc.!. Lle f6.lh. tollowoS rcsn (5€.?0315
<br />Businc$ ad Prolqsion Codc): Any Ciry or Coldt *hth Equircr a Ftmi ro @o{ru.t..lkr. inprow. &mlish or rcpin dy
<br />smcnft. nrior ro irs is.uaN. .ts ,cqui6 lhc .mli@r aor such |Emil lo m. . siSmd slll.mnl lhal l* or shc ii liccn..d pufttd
<br />ro thc pmvhions of rhc Conlr&rofs Licensd trw (Chlplcr 9. Commndng wilh S.clion 7000 of Division I of rhc Busine$ 8rd
<br />P@f.srioo. Codc) oi th h..rsh.iscxc,plther.from&dlh.h.skforlhcrllcgcdctnindon.AnyviolaiooolsdlhnToJl.Sbyan,
<br />rpplicanr for . r,emit subtrls rllc appli.afl ro o .ivil pcMhy of flot mrc lh!. fivc hurd,Ed dolh.s (1500).
<br />_1. !s oqa* of lhc tfrrcny. or my .mplo}ter qirh sa*es ei theh solc .orrlEDs.rion. wil do th. *ork !d rli .rmte is ml
<br />imdd.d or orcEd tor elc (sc,70{4. Busiress ed ftDfesbs Codcr TIE conEeiols Lien* Law &Es iol ,pply lo o owN of
<br />thc proFrry who t{ildr or itrpioB dEFtr.!d who drB sh s haffclaor rEBllor rhmuSh hk or hcr o*n cmployc...
<br />pr.vidcd ih s.h inFnEmnrs e mr htcd.d orofrcr.d lor sb. l( lF$46. tlE t{alding or inpftEnl t $ld wkhin orc l&
<br />ofconot hn. tn Oqn( Built6 will luE lnc tdntn olpDvi.g rhlt he o shc dn @l hik or irlpm@ dE poPdty 6. tE puqbs of
<br />.H ,s osrcr of tnc ImtEny. rm crclusircly conlmctinS with liccnFd mnlraclof to onrrtrr 'tr PmFd (Se. ?04,1. Bosirc:1
<br />PrDisbn Cod.r 'Ihc Conrra.iork l-ic.n.c hw d6cs nol apply ro s. ownd of prorcny *ho l,lildi or imProvct $@on,
<br />who coilmdr for slch prcicrs eilfi a Conhdo(s) ltcnsrn DUB@| to rhc Conll.&roar Liccns t w).
<br />I r .(tr1rr rRtrr Sr.n.
<br />x"",ot A+tHa
<br />DICLIIBAIIIIN
<br />I hncby ortrh und.r Fnalty of pdjury o* oallr fouo*ing delddions:
<br />I havc rd will minrlin r CeniaElrc of Conscnr ro S.lf'lns!rc for wor*s compenrnioL a\,'mvi&d lor by SNlion 3700 of ths
<br />lnhor Codc, for rlE p.rfllffi of rlE wrt tor whhh th. p.mil is nsu€n.
<br />I havc aod will nrinrain workcrC compcnsll tun insu.rncc. e! requircd by Sdlion 37(x) of lh tjbot Codc. for lhc p€rfo.rlM. of
<br />rhc sork for whih lhii Fmil ir issrcd. My workss on{Ensdion insursncc cari.r lti policy.umbcr m:
<br />lr,la, Nutr,hc'
<br />-l\tnc.zlIJ ccirb rh,r inrhc rrf"mft. orrh.work rd whkh ihir p.rnir h hsucd,I shall ml erlplo, an, F^on i. a.y n6mrrus ro trom .uoFr ro rtrc qmkEr, mmn nsrmn la*s of clliforni!. lnd asB rnd if I .hould h.om subrccl lo ltrc
<br />wo*eB..opcnerionprcvi\ionsofSdion3T0OoflhctiborCodc,lshell.forlhwithconplywnhttssprcvisioni..
<br />WARNING: Failur ro sua mrl6' oopcnsdion .ohEgc ic unlawtul. and dEll subi.l u cflPloFr lo Eimin l !.mllis 8nd
<br />civil nnci up ro oE hundrcd thorsnd .lollB ($100.00,J), h .ddnion lo lhc rosl of conpcs.tion. daM8.i N Pmvidcd for lhc
<br />S.cri.n 10?6 ofrlE Lrb.r C.dc inrcrcsl ed allomy s f..s
<br />6 qEIEL ?+IAI4
<br />LrcINS.ELIONIAACIT'A
<br />IIIIIJ.BAIIOIIIhcrutyultorudrrp.dlry.rFrjury$.tIa li..nyn undcr Imvision oichatls 9 (c.dmn.ios wi,h sdbn ?dD) ofDilhion l
<br />oi rhc 0usimssond l\ofesionr Codc. dd iy li.cn* is in tull rohc
<br />"rxt
<br />ctIccl.
<br />coll.trBlgll0lJ.rNlltNc-d$liNcr
<br />I hcEhy 0tnmunner,,cnrlryolNrjuryrhar rh.tu h a mnnodio. kindinS !8!ncy lhr lhe pslonurcc ofrhc vorr rot whi.h rhh pcrnril is
<br />issu.d (Scc 109?. (lv C ).
<br />APTIILAII.DECLAIAIION
<br />I hmt, trmnn nnds r.nalr, ofI,. jury onc ofthc folb*in8 d.rlnmrion!
<br />o.r)l i Pcnni'$Arb.(os Norilicurion Frq,cr0l RcEuhli,,n\ ('lill..to. Pad6)
<br />-Rcquncd
<br />bxcr ol Notilic.li0n
<br />l-cnrlr rhxt rh.l.J.mlrcgulJrhn. rcFffJinF trLo.'.m,'.,lrc n, Jnnhrhl,'r.rhN nFFcr.
<br />frAd'lyrhd IhNrrcJ'lrhh pflrrLotrrtrd {.rc rhdrrhc0tnvc irlnflMnr hcomd LFL{ u ..npry wirh 0ll ciry lnd cornry
<br />',^lnBn..\ ond Srtrrc ljrs rcUrin! k, hu'ld'np (.nrruLr'otr..rd h..cb!.urh.rizc.qrccnldircs olrhn Ciry Md A,unrylo ctrrn up.tr thc
<br />sholc tunrion.d ptr,pcny fn ini D.dr i( r purBFcs
<br />K,h.r,tr^,. sisni,. d2firr* ,',,,, ot-/tr/zot?
<br />fETEF--?tL{-04
<br />Appliances
<br />[/]etal 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 />Vents
<br />Toilet Room / Clothes Dryer \\flre 'z,M6s)
<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.E"r\5\8 r //LEtfr
<br />Final Test
<br />Meter Belease -,..2
<br />FINAL //-tr-/8 ,47*"t4t s 2')
<br />Notes, Remarks, Etc.
<br />X
<br />)
<br />Grease Duct
<br />lnstallation
<br />--------T------
|