|
MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS oWNER ITUILI}ER DI]LCAR TION
<br />I hcrchy rlfirn undcr Nrilry ol pcrjury rh l n cxcmnr linm rl'd- C, rrrorJ l-i.cnsc t.rR lar rhc l'oll()win! rcr$i (Scc 70.115 "
<br />auiinc{\ rkl Piintsion C.nc): Any Ciry or Cortrr, *hich rc,tuncs d rr nr t' ..n(dcl. rl'cr. irnlrorc. J. rnh 'tr rq'xn J y
<br />(rucx{c. pifro ns nruJm..rl\or.qoirsrhd{tli.ntrlarsu.htriinirrolil.r{igmi\rlrcnrfr rh r l'. or shc I li.ct*d nnr\uanl
<br />r, rhc IRrisi(* .l rlr C.rrndoi\ l-ic.nscJ l,aq' lCh:!prcr 9. (innnr.i.nr! $nh Sc.rion 7(XXr oI l)irision .l of rht Bosinc{ dd
<br />l'rr'cs\nn (inlc)orrhd lror\hr i\crc r rhcrfnnnrnd rh.lr6ir tur rhclll8cdcxcmfion nlviohrionofS..ri.nX)ll5h!my.
<br />attli.iri nlrr|t ir suhjcchrhc rtnlicul r. ncivilncmllr.r nor N,c rhrtr li!. hunJrcdJollr\ (sstx)).
<br />-1.
<br />!\ o*ncr ol rhc pmp.ny. .r nir- c \ru)$\ sirl sn!c\ rs rhcn v,h .ompctrs*n,n. will do rht so* ind rlf, slnrturc i\ mr
<br />i'n.rkl.d oroffctod (tr sL (sN 7u1,1. Busnrssrnd l'rons\ion\ Colcr'l h. Coirrcttr \ l-i...\c t:,s docs .or ippl) lo rn oqm! or
<br />rhc0n,I)tny sh' huiils or inDtrtrrs rltfr"r. snd *h, dtE str.h $l)rk hn \.lforh.rcll.r rhou8h hn or hcr own cmpn,Jt!
<br />p(,!nkdrh isu.h nnpn,rcnrnrrrcn i,rctrdcd oroflatu\l for *'lc ll. ho$cwl rhc ttril lifE .r inDDvcnrnr is sld wirhin onc ,td
<br />o{con{'biiur rhc Osncr BuilLr sill hrr. Lh burdcn ofplrliia rlu lt ui nlc dil r huiltl or i'npn'vc rhc l[,rdy lnr rhc Puqr)t.l
<br />/Il.r",,nr(,'lrh.r,Drri!..n(!!lu\tr(h(trr.trrrnswithli&n\cJcotrcttr{h.onflrthcnmrc.r(Scc?(pr.BD\i't\\iil lh,rs{,nCuJc l'hc(i'ntx!rui\l (rn\.l x\ 'l.csnorrmlrtuoosncrof l]()ptny*tu huikl\ or nnpR,v.\ rh$con.
<br />rtrd sho .o r r\f.r {uch pn+crs *irh a Conrruclo( s) liscn\cd !u66nrbrhcc(, 'x.tr'r Li.c.\c trw)
<br />llgn-Brllll\
<br />I hcrcby afaim uod* F.alr, rf Fljury o,E of lh. lolk wi.8 de!r.rio.s:
<br />-l
<br />nrtc &l I ill ruinrin r Ccdifi.ic of Cor\cnr tu s.lf ln\urc ror v ,lkcs oarpcnurion. $ prcvid.d i6r by sccrn)n lT0o orthc
<br />Uh.r Codc. ld rhc Fnbirnancc ol rhc so n, shich rhc pcrnrir is isx.d.
<br />-l hole ond will mainrain wort6 compcnsalion i.suoec, as nquied by S(tion 3?00 of rh. Libor Codc. lor lhc l,erftrnmc of
<br />rhc wort for *l ch rhn pcmi ar hsr!. My *orkcn omlc srio, iGtrl.re fftI ad policy numhd dc:
<br />ff*n'ryon*rr*p..r",nuRorrhc-o,*rmwhichfiiipcmirisis.d.lshlll.ot.trrploy.nypcrs.insnyMnturd 6 b b.com shjEr ro rhc wtrk6 omFrsrion IrH or C.liloDia. and aSIlc lh.l ir I shoukl lilom $birl lo lE
<br />sllda onw.stion prcvilion. of Sc.lio. 3'100 ol lh. tibor Cod.. I slEI. fonholth otlply wnh Oo* I,DvisioB..
<br />WARNINC: Failurc ro surc workcn m'npcnsdbn covcBse is unl,wtul. 0.d shtrll subrrl on cmlto'lr lo dinind FrultiB lnd
<br />.iril fincs uI lo om hudrcd ltousrd dollars ($100.0t)0}. in addirio.lo lh. con ofconD.r$liotr. .km$s $ F,vidcd f.r lhc
<br />Crnc. inlcrc( ond allffrcr\ iccs.
<br />Z,O q /,
<br />IICIINIEILIONI&I(IUB
<br />DEELAM.IIAN
<br />I hcrchy aifin. unds FmlrtorIrljLry rh,r I nm ltin{d trndcr Irori\i.tr ol Chrfls 9 (conrnEo.ins {nh Sccri,n 7ffx)) oiDivnion 3
<br />ol rhc Bulim\srM Pmri$ions Codc.orxi trrr liccn\c is in tullnncc Dd tffc.l
<br />: Lic.N Nuhttr:
<br />!;ONSIIJJIJI!}NII;NDINCAGEITT
<br />, hurch! rmntrund$ Fn,hyorp.rjDry rhnr rhcrc t ! coflslflctirn [ndine ugency Ibr rhc Frrornun.c orrhc *ork fn shi.h lhn Fnnir i\
<br />ksued(Scc 1097,Civ C )
<br />AIILICANLDEIIAAAIIAB
<br />I hs!-6y !trm ondcr Fnllryorp$jury onc olrhc rolkr*ing d..lmriotrs:
<br />Dcnroliio. Pcrmirs'Asbcsros Norificarion tjcdcrulResuh ion\ ( lirlc 40. Pd6r
<br />-kcquncd
<br />L.ncr of Norirrcdi[
<br />4 Lr,.n,ty rnn u* t",t*,t rcaul iaN Essnins a\hcsro\ rcnDral rrc dorrmli.rhlcro rhisrmjccr
<br />fA.-nnr,nn, *,, *"uun\ rrnhrrtr'n rkl {rrc rh rlt r&rvc inhnnrion i\c.qrcr.I xgN ro.rNpl, wirh rll cny rnd (bunry
<br />'lfr,lnoncs mlSr ull*.r.urnsr.hd'ldnrc, rrtu trm. ld hcr cby.urhorizc rcrc$nllr iles or rhk Cir, ed counry r) ctrlLi uJn,r r,r
<br />rhrc Hnri{,ncd lrr,nony ntr
<br />Antlictrnr or Arcnr Signrllrc:^",
<br />py'e/zaT
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Duct Work
<br />Pre-lnsulalion
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rouoh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer t,/..11-19 Jc(M lv
<br />Residential 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 />Above T-Bar
<br />Rough Mech.
<br />Meter Release
<br />FINAL I l\llq 1'tM)/.2 .?)
<br />Notes, Remarks, Etc.I I U
<br />Final Test
<br />lr '.i. \ \un,hu
<br />-l'\nnr\
<br />-
<br />L.ftlel1 Nrm:
<br />-
<br />I
|