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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARAIION
<br />I lErctry srrm und$ I,eMlry of Frjury rl[l I u crcmFl iiom rhc Conradou Ltcns rjw for Ih. following EMn (Se.?O3l.J'
<br />BlsiBs ard Pfl,fession Codc): An, Ciry or C,u t ehich rcqlircs a p.mn lo constNcl. !116, improrc. d.molish or Eton uy
<br />srrucorc. Fbr lo irs i$uancc, ele rcqur$ thc lpplicMr fo. ruch pcrmil io filc 3 si8*d sm.tu lhd lE ot ihc i! li..ned pusut ,
<br />lo rlE tmvhn,ns of tlE Con|nctoas Liensd L3e (Chrprcr 9, Commmi.E uirh S.ction 7000 of Divirion 3 of lhe Burin.ss and
<br />Prcfessioni Codc) or rhIr h. d lhc is ctcdpl tcrefroo aod rhc hris lor thc .lh8cd .xcn'plion. An, violllion of Sdbn 7011.5 by my
<br />applic!.t ror a p.ml subjNls lhc al'pli.a.l lo acivilpcnallroanot morcthM fivc hundcd doll@ 1!500).
<br />_1. ui ourcr of rhc proFny, r, ny emplorE. pirh Bagcs !* lh.t $h sry,.flslhn, will dd tlr *oit dt 0r slntlw is mr
<br />intcnrLd or ofr.rcd ror elc (SN.?044. Busimss and Pmfcsions Codc Th. Cotrrdcroli Li.cn* Llw docs .or ,rply lo $ owmr ot
<br />rhcpmpcny *ho huilds or impmrs thdsr !d who d{F $ct wlt himsclf or hersltor fircu8h hk or hcr own emplo}rcs.
<br />potklcd rhlr such inp'owmf,c @ mr i.l.rn d orofinrd tur sL ll horcffi.llE t ildiq or inpswmnl is $ld *ithin om r{e
<br />ofmnglcri,n. tlE Owm BuiH.r *ill h,tc dF hnlcn oattuvine $rl lE $ shc did ml itrild or irymlc tnc pmrsly for t,t llrFc of
<br />_1, us owrc. of rh. Fopcny. !n cxclusivcly conr{ring wnh lccn*d conracros ro oniltu.r lhc lhFrr (Sc. 70a4, B!\irc\i
<br />md Phfcssion codcr Thc Cont0clor's Liccn* Lsw do.s nol rrplylo !n oqncr of Im!€ny wh(, bualdi or imnrcvcs lhcrcon.
<br />!trd who ontn.rsfor skh prcirrr wnh a Co @rod9lic€nrd p!^@r brtE Conrrdols Lt.ns tjw).
<br />-l
<br />am.x.nfl undc, S.crion- B. & P.C. aor rnt rdso.
<br />D.l.r O*R.
<br />IIIBTE8S:.qQMTJNIAITON
<br />DECI.AEAII!]N
<br />I trrcby rrrirm und.r p.naxy of t njury om of lhc follo*in8 ddLrllions:
<br />I hlk and will tuinrzio a Ctnifi.d. of Conscnr b s.l| lrsurc ntr workcs onrE.srrion. c\ I,(,lidcd for b! s..rid ]?00 of rhc
<br />ljhtr Gnq l'or lhc Il(rforuocc ot ihc sor* tor $hich ihc ptdir n i\sucd
<br />Ih.v.andwill Einrlin *orkcN cotrpcnsatio. nrurrrcc. as E'qutcd hy SLtr ion l?fi) d, rh. tr&r Codc. for lh. ,)crl'olmrcc of
<br />thc work foi whi.hlhi\ Nrni is isud Myqorkcs co$pcnsrrh insurorcccnoicr uxl B,licy nudho dc
<br />1),c.F,c, Jrr1E t-t,r-rC/
<br />f.)q,ztl358t)6,i2 hl
<br />WARNINC: ltilure ro s!rc *ork€r $op.nsattun cov.hgc is unllwtuL lnd {tull sutjd 0n cnrlk,}tr ro onin,l Fmlris and
<br />civil fiics !p ro one huidrd rhousrnd doure (S100.fix)). i. ddirn,n ro thc cosl ofconf.nrdrion, d!tuses as prolidcd i(t thc
<br />S..rnrn ll)76ofrhc tjbr Codc. inlcrc otrd.irorrcy\ ies
<br />l/t
<br />LrCINSllLCOXInlrell)I
<br />Df,CLA&TIOI
<br />I h.r.by rlftn unner pcmlryol p.rJnry rhrr Idr li(t{d undcr lr* si( ofChnDr.rq(con mnci.gnirhSr..rion7fX)JofDir'norl
<br />ol rlE llulims\rnd Prcti\\ion\ Codc. arxl n,tlt.n\r i\ in llllnftratrdrffLtr
<br />lbt'7 ? 3 L
<br />7lz9 l)A,u/a alfut)
<br />r!,lsr&lJcuoNlENl2lNcll;[Nlr
<br />I hcrchy aninr!i cr n nrlryorp.rjury rh.r IhLrc is r consrfl.liotr lcnilirs nscnc, iq
<br />'hl
<br />pcr'ninm.. orrhc wor* tur u'hi.n lhis rnnit is
<br />nsucd (Scc.3097-Civ C )
<br />AIILICANIILCLABTIIOX
<br />Ilf,n{,yrl! und.r Ntrilryol tErlury.nc oithc l,n[,*i']!&.1 'rri{,x
<br />l)!nmliri,!r Pcrn,ir\ A\t"\ro\ NorilicrLoi li.d.rrl RcFulnrtr,n\ ( l irlc.10. t'in6r
<br />kcqtrncd lrrrorolMnificrriofl
<br />l.cnilyrhor ihc L'dcril rcSullrions Egordin8 r\hc(os lemul r. norlppliclhlc tu rhi\ tn,jc.r
<br />_;1:r
<br />ccnili rhr Ihtr\.rc rhi\ ?mli.dbn rd{.i.thnt rhcrhr\c inloirurn'n n corcd Irtrek,.onrply*irhlllCir)anrl(ou.ry
<br />odimtrccs md St.rc Lnrvs rulxrins k, huildins.onntu.rion. uxl hcrcbl,ulhdrir lcrr.scnlurircs r,{rhis Cir} rnd C.unryro ctrrcr ul)on rhc
<br />l}iNc nrtrridrcd lii'tx ) for i,r\tEcl ion I'Urlmscs.
<br />Aptlic"nr or Aldnr Signirurc Wa;i--'
<br />Zvn lV e-
<br />Appliances
<br />Ir/etal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />tl4isc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rough Ductwork
<br />Vents
<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 />Openings
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.fll/ts tb 6-6
<br />Meter Release
<br />FINAL {h(/t't 5$\<(
<br />Notes, Remarks, Etc.
<br />Final Test
<br />-l
<br />cenifylhlt in lhc !.nbrmnc. of lh€ *ort for*nicnlhir pcrmir i( is$.d.1sh,ll nol.mtloy a.y !c6on in lny munncr
<br />$ as ro h.@D suhjccr ro rhc *0*6 .omt!.nsdion laus ofcrlifomi., and a8rcc thlt it I slnuld tnoft iubixr ro th.
<br />w.&s'conFn\arionpmvirions{lScdionlTfiroflhctltrrCodc-lshlll.fonhwirhomplywilhrho*p(,!irions..
<br />L.ndcis NrnE:
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