|
MECHANICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS Ol{NER EUILDER DELCARATION
<br />I heEby dmm tIdc, pcnally of D.rjury lhal I m crcmpl 6Dh lnc Conmdou Lh.n* L.* for ttE folloqing E{$n {56.7011.5
<br />ausircsr a.d Prcfcisjon Cod.): Any cny or cou.ry ehich rcqoiB a |f,mn lo offitu r. .nd. inll'orc, d.mlsn or Epln My
<br />slrucnft. prfi b ir! hsumc. !l\o r.quies lhc ,prlica.t for fl.h Fmit lo uh r si8n.n shl€ft.l tltrr lE o. sh. i! licen$d pur$dl
<br />ro rhc povisions of rhc C.nlEclols Lic.n$d Law (Chaptf 9. Com...i.8 wiln S.ction ?000 of Divhion I ofrhc Busin.rs rnd
<br />Proa.ssions Co&) or rnar & or slt h .xcmpr ficrcfrom lrd rhc bcsiq ror rlE llh8cd cicmplion. Any {ohlionofSslion 7031.5 b, My
<br />applic! for ! p.mn sbj&:ls rh. roplic$t ro ..ivil pcmly or.ol mt lhd livc tun.lt d dolld (15m,.
<br />-1.
<br />&s owmr of rh. prllEny, m ny cnPtolEs Pnh waScs &( rhcit sl. Nop.nsliol' will & lnc wt ,r'd thc aMtu is ml
<br />inrc,i.d or ofi.Ed for $lc (Sd.7044. Buiitrs! rld Prof.srio.s C.d.: all. Collturd i Lienc t s doH ml !Ppl, to an owM of
<br />r,E potsry whot idr d in{,rews ths6n, dd wtn dG sh sll hiruclror heBlf or lhDush his d h.r ow..nPhrts.
<br />,mvidcd rh.r such imtmltftor @ mt inl6d.n orolI.Ed for sk Ii lbuffi. rhc t iEilts or idpmv.m' n sh sithin orc
<br />'tsolo,phrbn, rh. Owmr Buildd *ill hlvc rlE hfrhn of pmving thrl hc or slrc dil ml hlld d inPtoE 0E pmpqiy for th. l,!48* of
<br />-1,
<br />os own.r of rhc prop.ny. am cxclusitly @nulcling wnh li.cnscd conlr{los lo otrsltuct thc ror.r (ss. 7044. Busims!
<br />ad hofr$ih Cone: Thc C.nrra.lor's Lic.os trw docs ml apply Io ano*icr ofpoFnyvho builds or inlrovca theren
<br />dd sho onr@lr ftr such l,mFts *nh a Contelo(s) ltetred p!6M lo rn Conn&lo/s Liftns lr*).
<br />I am .rcmDr lndcr SKtiotr . B. & P C ,or rhn rcu$n
<br />lhrttdklwillnninkirrCcnificar.olCo{nrtrSclllNUruktrtrorkcrrcompcnsarn,i.aspo*}cdlitrbySc.rion.lTlX)olrhc
<br />t-rtxtr C,nlr.larrhc NrlonDn.c oilhc work l uhihrhclLrmn n '\{tcd
<br />-l harc ud will nEitrrlin {o.k B .on .ns,rion insur.n... a. Equn€n by S*raon l70o of thc trt r C!dc. itr thc Frr6tmm. of
<br />rhc work for whth rhis Dcmjt i{ ksad. M} worlR omlEnelion insutde.dic. a,n Pli.y nunher rc:
<br />Poh.vNu $cr:
<br />-Erpn
<br />s
<br />-l
<br />ccnify thal inthc lcrfortuneolthc mrk forvnththhFrmit h isslcd,I rhtllnol cnDloyrnyI'crwn indnymtrmr
<br />F I ro b<om sutj.rr lo irE mrftcl sElrcnsrion la*s or Caliaor.ie srd alN lnll if I fioull lEiom iubjet to llr
<br />so*cft @dp.nerion pmviions of S.dion l?00 of lhc Lih.r Codq t slEll. fonhwilh @trFly wnn rho* povishN..
<br />WARNING: FliluE ro sw *orkctr on{*nslion mEEgc is onbwtuL ed shrll subi{l e c,Uloytr lo dini..l,rcEl[s.d
<br />.ivil fincs !p ro oft nudt rl rhow,xl dolln ($1m,0(b). in .ddilio. lo lnc o{ of eoFrsrion, .,.Mgcs .s prcvit€d for th.
<br />Serion 3016 of rh€ L$.r Codc. irtcEn ud fl(myt ft.s.
<br />ullilsElll;oNr&lcrQB
<br />DISAXAIION
<br />ol rhc llNincsrnd Prolc\\nn\Cod.. !,xl nry li...sc i\ in rillritr..3' .ni.r
<br />IOIiIBICIIONI.ENDDIi.ACENCI
<br />I h.eby llfrm u.dn Fmlry of pcdury rhlr rhd i. . Nnirudi,. LndinS a8cfty for lh. perfo,r1@e of lhe *s* lor whhh rhir Frnn ic
<br />is\lcd (Scc :{)97, Civ C.).
<br />AItLICANLDllCLd.Ei\Illl!
<br />I hcrcl', ofim undcr Fnrhy ofFijury om olrh. rblbwiDs dc.lrnri,rN
<br />D.R,l nr Pcrnrirs Ashc(os Norili.ali.n acncral Rrs hrnnr flirlr{0. Pin6r
<br />Rcq0irql Lclrcr ol Norificdi,rr
<br />-l
<br />ccnify thal thc fcdcEl E8llarbns Eearding $b.sos rcmvrl orc nol lptltrblc 16 rhl{ PB}ll.
<br />-l
<br />errily rlur I hlvc Eld lnis appliclrion &d irarc lhrl $. {b6v. infomtion h coned, I agrc lo 6mply w n lll Cily and Courly
<br />odin!rcs ad Sr.!e L3es EhrinB lo buildin8 coflrrddioG ud hcrcby aurhoria rnrc$nl,l iv6 of lnis Cily and Counry lo .nl6 ulb. tlE
<br />.ho!. mnrioncd Iml,cny {o, inqxdioo purpc.s.
<br />Aptlliconl or Agc Sirnaturc:-
<br />Appliances
<br />Ivletal 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 Ranoe
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Fire Damper
<br />Openinqs
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rouqh Mech.
<br />Final Test
<br />Meter Release I
<br />FINAL V,rq\tB ,'OULA h)
<br />Notes, Remarks, Etc.
<br />Grease Duct
<br />D!re: O*fti-
<br />wonxpns tirlrprrt.s,lrro,'r
<br />DECLIMIIIJN
<br />I h.rcby rflirn und.r pcnlltyolFrjur, onc dtrhc Lllowin! dNlu nnrl
<br />Dar.:--
<br />Pdnile dm (priir):-
<br />tt
<br />-
<br />f-------T------
<br />IT
<br />i-
|