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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.oIINER IIUII,D!:R DEI,CARATION
<br />I hcrchy Jlftnr undcr pculry {)l J{rjrr:_ rhrr I m .h'npr lion, rhc Codtr(trr Li.cn\c Lrw lar rhc {blk)win8 rcnnin lscc 70ll S
<br />8urir.\! rtd P(nisn r Corlc) Ary Ciry or (butry shih rcqunc\ r jrnnir k, con\rn'!r. rlrcr, irnt,n,!c. dcnDlnh or rr t ut!
<br />lo rhc
<br />']oi!i.n(
<br />oirh. (hnti.nr'( l-i.cr\cd Iiq ((-hrfr$ 9. ComNNing trirh Sc.lion ?rxxr ol l)ivi\ior .1 of rhr BrjtrL* lnd
<br />rp,,licrii ntr rtrnrir\trhjfth rlB rnl,licanrro rriviltc rlryolmr nntrrrhm livr huftir.d dollir\ (55U)).
<br />-1.
<br />as owmr oa rhc pmlcrry. or Dy cmplot€s *irh wlscs as thln $b ompcnidion. *ill d6 rh. Mrl ald i* $nrlw is mr
<br />i.lcnd.d or ofrcrcd r{r sle (Se.7044. Ausine* $d Pr.fcsio.s Cod.r Thc Conh.lols Lians Llw docs nol .rpl, ro u owrc. of
<br />lhe nDrEiy wls lxildr or irymws d.en, ud who dc tuh s,.t iin*lf or hs€lror thftt8h hk.r h.t owtcmPloyes.
<br />lroviddl lh, such in{mwmnt m ml int.ndcd or ofi.En hr sL ll lbww. tlE ttrildinS or iryl@Enl ir $ld *nhin nnc }!d
<br />of conpkrio[ ltE Ownr BuiBd will hlr rhc hurdcn oapmvin8 tfiat hc or shc did ml t{ih or intmle the pmtcny to. 0E plqDs of
<br />-1.
<br />!, owtur of rh€ ropeny, m excluriv.ly .onra.rioS airh liccnrd conrocb6 r. sn$dc tryoj.cl (S.c. 7o{4, Busincs
<br />un hoftrsion Codc: Tlrc ConrBrol s Liccnsc Lle dcs mr orply ro !n owod of prep.n, *h. builds 6r anpbrcs $.ro..
<br />and who .!nrre!i for sEh projels wnh r Conrdo(, li.cnsd pur$anl io rh. Conrn lols Liccns tiw).
<br />I nn, rr.n,Jn tn,l.r Srcr A.&PC foi rhi\ r.inrn-
<br />lo { /h"J
<br />\'( ,l{F L\' ('r )[ridN sAIx,N
<br />Dtt]L,\trtlt()N
<br />I lFrcby 0fiinn und.r Fn.hy ol tnjury om of th. followine dcLr ions
<br />t-rhtr Cotle. lar ih. !cn.'Dun.. oIrhr r.rk tur *hi.h rh. |f,nni n i$urJ
<br />I h,vc a.d eill 'Minl{in work tr coqEncalio. itrummc. f,s rcquircd by Salion 1700 ot the khor Codc, for lh. DcrlornMc of
<br />lhc work aor which lhk p.rmir is issrEd. My worl(s comp.nsolion insurmc ..ricr {n llolicy tunl,q m:
<br />-l
<br />ccdify
<br />'hd
<br />in ihc psfonmmc oi lhc uork for which thn p.rnft n hsucd. l snlll nor cnpl{ry nny p.non i sny mnncr
<br />s N ro lls.k rubixr t,
<br />'hc
<br />wrkc6 .on{xnsr ion l,ws of Cllirom[ ,nd led rha' if I should lx{om slbrcl ro t,.
<br />wo.rcn'omp.nslionpmvkionsolSdion3TfiJollhcLltnCodc.lshlll.fonhwilh.nnllywirhliospnviiirn\..
<br />wAtrNlNG, Frilurc t, e.ur wortcB .ompci$rnm ovcogc is unlowrtrl. ,nd shall subjccr m cnrllolcr ro ri'ninal l,cMltis and
<br />civil linc{ up to oac hldrcd rhdlsand douad ($100-m0). in addirt,n to rh..o\l orcom!.nslion. d!ro8cs as troridcd tu lh.
<br />Sccrion 11076 ofrhc Iitrr(-odc inrcto{,nd
<br />lo I ca; v l/.^^
<br />ol (hc llu\irc\\rnd l)roli\\i,n'\ Co,lc. rnd nry li.cn\c i\ in ftrllf{R!a cllari.
<br />Liccnsc Class Liccnsc Numbcr:
<br />Dd. aonlElo.
<br />APPI ICAN'T DD(]I ARAT( IN
<br />I l*Nhyrnnmu r! Nnrlty olperjry onc ol'rlr r'oll()nnrB dc.lantlion\
<br />D.nxnirion I'.rn,iis A\hcsk^ Norili. i( Fcdcrrl RrBuhridxdnb 4r, Pnn6)
<br />Rcquirci t ncrof Norificrrion
<br />I en iiy thar !h. fcd.ral rcEulations ESardinB astEsros rcmul urc not {pli:lblc ro rhh tmiil
<br />l.dift rhd I hav. cad rhis aFrlkdion ad {atc rhd rhc 0ls\c infomrion iscoret.l agc rocomplysirhrlt Cny!6d Coumy
<br />ordinlnccs md Srurc li\a mlrring ro huilding.onitucrion.,rxl lrrcbrlur ^ry:..:::)il;"-
<br />1lh' l<i€o
<br />rbvc nrnrionlai nrlpc'r, i{,
<br />At'nI(MI or A$nr Stnururc U\
<br />M u CtlAt)
<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 />Vents
<br />Toilet Boom / Clothes Dryer
<br />Besidential Ranoe
<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 />Rough Mech.tltttl>7-li .Avr4*
<br />Final Test UI
<br />FINAL t^l?lt( |4.ilprA-lKv
<br />Notes, Remarks, Etc.tl
<br />COMMENTS
<br />Other
<br />aD)
<br />Meler Release
<br />cL (L lt--
<br />I.:ONEISUCIIIINIINDINI].&qENCI
<br />I hcEhy llllirn under Fntrhy of pcrjury lhd thcrc is a .on(octbn lendins ,s.my for rhc perrotuftc or rhc Ror* for shirh rhh lf,J'ni' i\
<br />issurd (S.c. :ltr97. Ci!. C ).
<br />tr' rlc' . \utrr
<br />=
<br />I
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