|
MECHANICAL.INSPECTOR RECOHD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I ficrcby ltfrm !nd( pcn,lly .f F jury lhd I M cicnq t.m thc ContrsctoB Lienc Llw to. rh. folouins r6sn (Se.7oll5
<br />Busiicss rrd PreL$ion Codc)r Ary Ciry or Couniy which rcquircs s ltmir lo m.nru€1. dls. im0ovq &mlhh or rcrEn 8nv
<br />suucturc. prior ro ns issuec, aho rcquircs $c appliclil for slch fmir to lil.. siencn slalcft.l rhd lt or slE n fiened lllN t
<br />ro thc Eovliionx oftr Conlrslols Licencd L{s (ClEflcr 9. Commrcing wth Scciion ?000 of Division I of$. Buiincrs 'id
<br />P$fessionr Codc) or thai i. or shc ir.rcnfl thmfiomsnd thc bsis for lhc !l hg.d .rcmpt ior ' Any liolalion ofs..l6n ?031 5 byanv
<br />spplicant for a p.mir Ntjsrs rhc lpplica to ! civil p..!hy of ml turc lhu alvc hundrcd dolldrs ($5OO)
<br />-1.
<br />!r oercr of rhc poFny. or my cmrlhrt\ wnh w,8.s ts rh.n $t omp.rstbn. vill .lo dF worl on llE srnxlr h mr
<br />intnd.d d o6.En for sE (56,7014, EusiBss tnd Pmfcssions Codc Thc ConlBlor's Ltc c Ll* docs mi orPly lo 3n owr of
<br />rh.ImFrry al$ hrihts o, irymrs lh.mr ud who dG *h *o* hiB€lf or hcBlaor lhDlgh hb ot hcr o*n enplovccl.
<br />flrvid.d rh.r skh impm@ds e mt inte'id oroff4n t for sL.li howsi lhc hr ding6r atpmwm hsEqnhinoncF(
<br />of 6n0hii,tr lh. OwNr Buildn vill hlE llt htdcn of proving 0ur hc or shc did ml ttuih or inqhe 0E tmFny for llE I'uqDs of
<br />l. rs owncr of rhc t'rcpcl|y- m crchsnrly mnttrtin-r wilh licensd conudo6 ro onnel li. pn,iEl (SB. ?O4a- Bu\incs
<br />ard Enltirbn Corhi Thc Conlmlols Liccn$ Lle do*.or irplyto eowncr ofrmFdy sho huilds or iml,rcves lh*.on.
<br />snd vfio s.trrcrsfor such rftjek siihr C.nhclo(, liccnscn lusudt ro rhc C.ntractols Lic.n* tiw).
<br />_l m er.mfl lndf Seri,n-.B. & P.C for thlr F.r.n
<br />woRI(arui' coMPFIlsATroN
<br />DECIdSAII9N
<br />I hcrby amrm und.r pctully ot pcrjry om of lh. followin8 dc.hntionil
<br />lrhtr (ixic. ln, rh. ,[rlori n.roirhcwork lnr\hichrh.Itrn,ir n n{tr',t
<br />-I
<br />h.v. lnd willmrinhin sorlor' co,t{,.6alhn insu6r.., as rcqlircd b, selion 3?00 of llE L!bo. C.dc. ror lh. PcrlbrMc 6r
<br />the wo,k lor which thn pemil h icsen. My work6 .oqEnslion i.i!6n c cMtt lld policy ntmh( &
<br />-,
<br />anify rhll in rhc lx.formN. of lh. work forwhihrhkl.rflr is issu.d.l shlll nor cmploy rny per$n i. lnv m ncr
<br />e $ ro tE@@ subj.cr lo lhc uorkc*'fl'nrcnuion ltrws of Clliioni!, ud osc lh,l if I should bccont suh.i.ci lo rh.
<br />so*os.oopcnsdn,n,mvisk,nsofSari,n:1700olih.tiborCodc.Ishdln,nhsnhcoftPlywilhrl$sPovnions,
<br />WARNINC: Frilurc ro soe rorkcG omFnsalion oleBsc is unliwirt. rnd sholl subj.( 3n cmploytr lo aininal FMlrid and
<br />.ivil fines W lo om hlndEd lhoui&d dollrs ($100,U ). in oddilioo lo lnc cosl of coh!..srrion. dtmg.s as Prcriddd ror rh.
<br />snrkrn 3076 of thc Lrtnr Codc. inr.rcst 0nd atlnrcy s fes.
<br />d
<br />LllliNsEllcorgllcraB
<br />DES,AI{II!]N
<br />IhcEUrflinnxdorlrnrlyolncrjurythatIurlilr{dund$lnovisionolChaprdr9(onnncnciD!*ilhs.di{)n7(xn).fl)ivirion:1
<br />of rh, ausirEsrand Pn) fclrn, ns codc. uxl nry liccn* h in full ntrr tuxl.lL!l
<br />3
<br />CONS-TNUC](}N ! FNDIN(; ACFNCY
<br />I hcrch, rtfirn trndrl,rMlIyollE juylhar lh.rc is d.onnfldion lcndi,S ascn., rd rhc t binutrcc.lrhc work ror {hich this lErnrir is
<br />isrucd (SLr.:109r. Civ C )
<br />APPI,ICANT DI'CI AII,{'TIoN
<br />I lfr*ryrrli ! cr F.trklryolfcrjxry otrc ol lhc (nk,wirs dcclJrrn,n\:
<br />l).nmlirn,tr Pc nir*A\hc{o\ Norifi.nri{,n l:cdchl Rcguhrn s IIitLc to- li'n6)
<br />Required l.ctrcr ol Norifi cdi,)n
<br />l..nifyth,t rhc icdcrnl rcPrhrn,n\ rcsddins nst{nor rcm,vrl rrc nor.Illicnhlc ro lhl pDjc.i
<br />4it..r, ,n, , ,,.. .uo ,nr rnrlNr ii'n JJil {rtc rh r}t abovc irloirBrid t..ftc.r t usre lo curply wirh .ll Cir v rtrd Counrv
<br />.,rdrnr'ncc\intlSrrrclr{\rI'r'n3r.hu'lLln!conn.,n,n.rdhcr.byonrioriTcrcI'escn'divus()llhkCily0ndCounryk'cnrsuFnlhc
<br />Applic r orAgcnl siBnrr ,,. t(
<br />Appliances
<br />It/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
<br />Residential Ranqe
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />Openinqs
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.
<br />Final Test
<br />Meter Release l'1
<br />FINAL 2-n-n **.w
<br />Notes, Remarks, Etc.
<br />Drr. -. Orn.r.
<br />- l'r'1" q
<br />*,, s+)- ll
<br />L.nd.r'r N.m:
<br />-
<br />ahnc nEnriord ptulrdy ror ins!.crion _*.,.s-il-t'
<br />{e41&4p
|