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MECHANICAL.INSPECTOR RECOHD
<br />DATE ID/SIG.COMMENTS oWNI]R I]IJII-DI]R DI]LCARA'I'IoN
<br />I hcrrhtrrfir ondcr I)cMhy r)l pcrjuy rhir I aD cxcmtr liom rhc Onrirlcitrs l-i.rns. I-ns ntr rhc Lllowi,rs r.ir-,- rs". tu.rl5
<br />Btr\incs id It lcssi( Codc) Atry Cily or Counly shi.h requircs r Fnnir kr ..nsnrcr. rllcr. imi'ovc. dcNni\h ,r lqln . iy
<br />ttolisri,nr(Codc)orrhir hco.shc ir crcmfr rhcrclrn'nlnd rhc hrsi\ nrrhcnlLlcdcxctrrpli r Aryvnnnrionofsi.rit T{rrl5hi.tr'r
<br />rpplicrnr litr x r.rnir \uhircrs rlr rptli..nrri r.rviltrmlr!.lmr nnnc rhrf lir. hutrJdlnolhrs (.$5{x)).
<br />l.rs oBncr ol'rhc p0|rnr.or i,y. otcc\*irherS.srsrhcnqnc.{nrNfsarnnr.rilld.rhc*orkddrlr{nrrurci\ n
<br />rhctr'l{'ry sho btrrl(h or irn,'.ovc\ rhcren. anJ qla, dms s'.h work hnn\clfor hc'rcll.r rInnrgh hi\ or hcr owt cnrrL,,ycc\.
<br />l. ,s owmr ol thc ,mF.ny. !m crclusivcly entrrcrin-q eirh licend *,nrt!.ros ro o6lrud ttr pmiEl I S€c 7044. Businc$
<br />lnd h!ftsion CDdc: The Conrn ror's Li.c.sc L!* docs nol .pply to an owrcr of tmr. ysho buildsor imrrovcs rhcrcon.
<br />rnd who .onrBrs for sch pmlccrs wirh a contracro(s) lirnscd nr6u,nr ro lh. contraclois Liccn€ Lns).
<br />I amcrc,npr utulcr Scct
<br />woRl(lrls' coMmNsaTlolt
<br />DECLAf,A]JA!
<br />I h.rcby lffirm lnds !€nahy ot !..jury 6nc ol $. lolkrwiog d(lmrions:
<br />-l
<br />h!v. ud will minrain . Ccnitr.re ot Cons.nl ro S.lf-InsuE lor vortss omp€nstion, &r t)n)!il.d for by Selion l?m o, rhc
<br />tihor C!dc. for rh. Frlormtu of rlE w6r* for *hth rhe p€mil i! hsucd.
<br />I hrw a.d willmainlain wortcls compcns0rhn insunrcc- as rcquiEn by Sd io. l70o of llrc L.hor C.dc. aor rh€ lcrronMmc ol
<br />whkh rhis l.mir is istu n. My woik* @mrcnlarirn arsu@. .nt .id poliy nu
<br />OozrlQ*,A o
<br />4.*'y tur 'nr* r*,rn *m nt ,rr wo,k ro, *hkt rhF rc,m tr
<br />; s ro l[com 'ubiNr rn
<br />'hc
<br />wdkn. .oml.nrd on b* \ or C.hfomi..
<br />eo*c6 .omn osrion DovasioB of serk f, 37m of fi. lahor Cod.. I
<br />hsued.l snallml cmploya.yDcr$n ina.y manncr
<br />mn !-!E rhor iII qhould lxcunE subFcl to lnc
<br />shlll, aonhwirh.on ly wi$ lln* ,mvhion\
<br />WAnNNG: Frilurc lo surc mrkcr' ompcnraln,n cokEsc n uohwtul. and snall subj6t an cmPloFr lo diminal lEmhts lnd
<br />civil 6nca up ro onc hrndrcd thousod doll6 ($t0o,m0). in addnion to rh. co( of ompcnsarion, dlnBgcs es [ovidcd aor lhe
<br />seriotr 10?6 of$c t hor Codc. irrcrc(,od ontysrc6
<br />,",", o?lZ:?.911) n,0,.,,,Fa,L
<br />I !(:FNSFT) (]oNTRACToR
<br />I'ECI.d.BAIIQN
<br />I hrrbya1ft u d.r lcnnlr! ol Nrjmy rh lamliccnEdu.dcrprovisionotch,lrcr9(c.nnN,cins*nnS$ri,n7Ox,ofDivhion3
<br />of rhc llr\incss rnd Pn,lts\bns Codc. d ,nyIiccns is in aull iore d clfccr
<br />aGql3
<br />o
<br />IANEIBIJ1;.II!)]IIINDINGIIiENCI
<br />I hcrchy affiflnntulcr pcndryofpcrjuryihtr rhcr. is i cotr{ru.rion kl\4rS !8crcy tu lhe 0.rfornrkc orrhc qort lot s'hin ihi\ Fr.'ir i\
<br />i$tr.d (Sc..1097. aiv C r.
<br />ATTLTANIDICI.Af,AIIOIS
<br />I hmby anim u.dcr Fnally of Frjury om of rhc followins dftl&rrions:
<br />Dcmlirion Psmirs Asbci rol Nori fi.ar ion Fcd.rol R.rularions (Tnb 40, Pan6)
<br />Rcquncdblrcrof Norific ion
<br />6=.",,,',,n,""
<br />i'is asbcdos rcnFvrl aE d.'.rplicahlc ro lhh pn,iccl
<br />and st0rcrllal dr atnE ir,orm ion n cod..' I trSreloc.mtlysilhall Cirr3id Counry
<br />rnd hc.ct y lulhon* rcparcnr.rivci orrhis Cny!.d County'o ctrrd ufi,n rh.
<br />,,,,,. OZ-Rr?9tb
<br />Appliances
<br />l\4etal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipmenl
<br />Duct Work
<br />Pre-lnsulation <4-(aJ )ze"h 7
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rough Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residentral Ranqe
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />Openings
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />lt-1-vb T$J
<br />Rough Mech.
<br />Meter Belease
<br />FINAL lo-l-/y
<br />Notes, Remarks, Etc.
<br />\/,U 044'<,rt lr$htltg (-v,kacuwl
<br />APPROVALS
<br />Above T-Bar lbee.*t
<br />Final Test
<br />XWJ(I
<br />,K'
<br />EtY\ o4-
<br />o-?"oc.\-er"A
<br />o*",OI--
<br />t ndd'i Nm:-
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