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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE tD/stG.OWNER BUII,DER t}EI-C RAlION
<br />I hcrchy rrftD undcr llnrll, ,,i tcrjury ilu I m cxcrnpr rmr rhc (ln nck)r' l,iccnsc In* n, rhc tulk winr rciwn (Scc 7031 5
<br />Businc\r lnd Protc$ioi O c) Any City or Counry which rcquncs . Pcnnir b con{ocr. ak.r. inlprovc. d.ftnnh nr ruF'n nny
<br />nrucrure. pri{n n, ir\ hsuri.c, aho rcquncs lhc amlicml lbr suchpcnnilro filc! \ictud ndrNnr rhrr tEor shc is licehcd pururnr
<br />ro rhc pmvisions ofrh. Conlmclors l,iccn\cd ltrw (Chrprc' 9, Connkncin8 wirh Scdb! 70d) ol Divhim I ot rh. Btrsinc$ md
<br />ttolc$ion\ (rlc)orrhir lLor\hc iscr. rpr rhciuli.'h dtul rh.b$is for rh.11lcgc'lcxcmpli{nr Anyvn,hrn ofSccrionTl)lll5by0ny
<br />rytli.rnr tar r lr.mn subjc.r\ rhc lptlicnnl lo a civ il IBMlly o l'mr nnrc rhln fi\a hundrcd dollais (Sstx)).
<br />-1.6
<br />o$ffiofIhe pmFrry. q m,coplolss wirh s.g6 &\ En sb.onp.nsdon. {iI do tl* sort.!d dE 3lrt@ b ml
<br />ime'idcd or ofrcrcd for sk (Se.7(x4, B$ircss ed Pmfcsiofls Cod. Tk Co.ntclo, ! LEn* kw d..s nol lpply lo & owr of
<br />rh. !,!r.rry wt[ buildi or ntnoB rhc@., ..d wh6 d6ca !u.h ft* hims.lf or fuelf or lnmlgh ni! d fter own cryloyees.
<br />providcn $al iuch inpmwmnl3 E ml irlc H oroficni ftr slc If. hoEq, rtE i,rtldntg or inpm€mnt is sd wnhh om Fn
<br />of..npbio[ 0E O$M Brildd will hsw llf hir&n ofp,lving llEl fi. or sh€ did rcl tdild o, inp@E dE Fopsly for llt potPoc oa
<br />-1.asowncrolrhcFor.ny,a'n.rclusirclyco
<br />ra.ling rith liccnscd co ractoF ro.on$ru.t rh. pmirl lscc. ?044. Businc$
<br />ond krtssion Codc: 'rhc Conrrcrois Liccnsc Law docs oot oprly ro 0n ownn oi pmFny eho hlilds di i'rpiovcs lhcrcon.
<br />.nd *ho cohrMrs for such pojcds wirh a Co odo(9 lien{n llBm[o ttr C.ntmlols Ltcnsc &w)
<br />-l.mcrcmp
<br />udr S{lion- B. & P.C. forfiLr rcasn.
<br />-l
<br />hlr and,ill tuinhin rccnifi.arc olcon{.( ro s.liln\ure ld $orkcs'co.rtti\ t,!.1\ proridcdfo!byScclionlTmorihc
<br />ljbor Co.lc. Ior Ihc pcdornurcc ot rh. *ork fd whi.h rhc pnnn it i\\u.d
<br />l/h,trcinduillrutrJ'nwk.E(tnrr,!nnionrn\u.!n!c,isrcquircdhys..ron]Tmoirh.tihorCodc.lorrhcpcr,nnnccoi
<br />rhc aork lir which rhh Frnrn is issuc!. MywortcB smpcnnrlion insuranccc! .r ,nd roli.y nunr$cr m:
<br />laqls
<br />T I,,,", * ..5-,€,fvJs*.,I1*Q;,.,*","",
<br />s $ to h(um sobjcr ro lhc M*6' conF.srio. bws of Crlifonio. 6d acB rhd if I lhould b.Lom subFt lo lrt
<br />e*c6'onncn*riool,ovisioNofseri,n3?00oflhct2torCodc.lslEll.fonh*ithsq)lyw nlllos pmirionr.
<br />WARNINC: Faiturc t{, *.ur. sorkcrs' .omr.nsalion covcmsc is unhwfll. snd rh0ll suhitl an colro,tr lo oiminrl P.dllics and
<br />civil finc\ up n' om hundrcd rhousnd lollrs ($100,0{D). I dom8.s as l,ovidcd for lh.
<br />intcr.rt Md dbrmy s f4s.
<br />@ 8- eccn^r
<br />I hrEhy rindunder pcndlryolpcrjuy ihd I a liccnslunncrp.ovi\i,nrorCh.Id9(.o rntncirssilhsccri,nrT0oo)orDivi\ii)nl
<br />ol thc Busincssrtrd fnncsn,nr c. c, rl nry li.cns! is ir ltllfnen clicr
<br />2t)D q
<br />7
<br />I h.rby lrfrn under F.0lry or p.riury lill lherc is a .oislructioi
<br />issued lSe, 1097. Civ. C.).
<br />ing ,g.my lor ltE t.rfolrrrmc ol rhe wo.k ror *hich lnir Fmir is
<br />-l
<br />cc.riay rhd Oe l.d(dl E8rl,rions rc86ditrB &sbeslos rcmvlt arc nor tpdkabk ro lhn Pmj.H
<br />l.dilrrl l hn\c eon tht ltpli.atn'n od sr{e rh,t rhc nh,v. nriofltrlion is corer. I as@ rooq yNnh.U Cnya.d Co! y
<br />ordinanc.s Md Srd. ljws EL{illg io td
<br />ub.v. mflioncd pol.dy for insFcrioi
<br />orrhis Ciryr.d Counry to cnlcr ulx n tnc
<br />Apflicrnr or Alc SiSmrurc L"l?u.ltg
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Ivlisc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rouqh Ductwork
<br />Toilet Room / Clothes Dryer
<br />Residential Bange
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Fire Damper
<br />Openinqs
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rouqh Mech.
<br />Final Test
<br />Meter Release
<br />FINAL -? - l/- 19 ,a)
<br />Notes, Remarks, Etc
<br />COMMENTS
<br />Vents
<br />Grease Duct
<br />lnstallation
<br />rof,(Ef,t_soMPiltAllllN
<br />DECLAf,AIIAN
<br />I h.rcby aali.n !n&i penllry of pdjury orc of lnc followinS dalmrions:
<br />4
<br />,r", ( O,
<br />llndclsNam:
<br />-
<br />Lxnd.r's Adddss
<br />-
<br />rppr rciiiiiCi.r nrirw=
<br />I iBr$y rliim und.r p.ntrhy oipcrjuryone ollhc followins dccldarioi\:
<br />D.nmlirion Pcrmih-Ashcnos Nolilicarion Fcd.rrl R.snldio.{ (Tirl.
<br />'10.
<br />Pd6)
<br />-Rcquircd
<br />l-e s of Norifrdbn
<br />I
<br />II
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