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APPROVALS DATE tD/slG.COMMENTS olvNt:R I](rlLDt,lR DEl.( AR,\TI()N <br />I hcrcby!fln und.r |fmlr, olFrjury rhnr I er crtnrpr rtur rhc Conlra.ror Liccn\c Lrrv l.r lh. i{,llowin! rc,enr lscc 70.115 <br />Ilunnc(s ind Prolt\si.n Codc): ny cii! .r coudy whic[ rcquirc\ , t{_nnir h (oDrlrud. alrr. imni(Jvc, dcmli\h or rurui' rnv <br />srucrurc- prfiro ils nsurn c.aho rcqutcs lhc lnlrlicatrr lnr \khFnnirio filc! sisncd {ri.nknr rhd h or\h. i\ ti..n\cd !trBu.nr <br />t, rhc Fr,virn,ns of llE (inrlr cr{r\ l.i.cn*d Lre (Chafrcr q- Con ns..in! eirI Sccln'n 7(xn .f Divi\ion I ol rhc Eutinc\\ rtrd <br />I'tufc\\i(,nsCoJ.)orlharhcor\h.$.xcnlrlncrclion.ndrh.hnsi\turrhcrllqcdc\c,tii,)n AiyviohrionolSccrn,hT0\l 5hvanv <br />rDnlictrnrturrncrmirsuhj..lsthcaDnlicanrroacivilpcnrlryor.r'frtrcihrtrll!.hudrc{rd.l1$(t5lx)) <br />I. rs oN.crol rh. policny.dr lycnlnoFcswilhurgt\r\rh.irv,l..on[cn\!ri.D.si]ldorhcsolk.ndrhcsrtuloni\ior <br />i'cBlrdoroltcr.dfur$lc(S!r?0.1.1.I1tr\incs\xndPn,fcisioNConcr'lhcConkr&r'\Liccnsl:rsdo.snuranllvro!rownrol <br />rhcFn,Fty sln buili\ or nnprrcr r,rNn. ltn wts {l.s such Md( inn'clfor htrsllor rhmngh hi\.r hcr o{n cnuli'y&\' <br />povi,lud lhlr \'.h nntR,!. knrr c Nr inrcn(lcrl orofcrcd nn\rk.Il li)qcvcr.rhc htri nE o. n\nrtnror h $li $irh oncF <br />of..trl|)hrnn. rhcOwns Buik]cr $illhrvc rh.la8lctr oitmlitl3 ltur hc or \hc dil n hrildorimPmvc rhc rnrFnv lnr rh. !!'Jr$ of <br />l. rsosmrolrhc propcnr. r,ncxclu\ivcly.onltrcrin8 *ilh lic.ntd.titncro^roc.nnturrrht Ptuccr(Scc 7l!1. Btr\i'r'( <br />trd lbfs\i,nCodc:ThcConlracxtrrl-i..nscLn{.cs.or.nrlyroino*ndolnn,pcdtwlr'buildsornnpnrvcsrhctcoo. <br />rnd who lrnr{cktn \uch troicds qirh 0 Conlruclq( n likn\cd turuNr brh.C.itr.(tr\ Liccnsc tie) <br />I itrrcxcnrpl un(lcr Scrr B &PC turrhisrcNnr <br />DAI. <br />l*oRLF'Rs' (ltMPtNsaTloN <br />DECLAEAIO! <br />I h.rcby rffirm undd n naliy of pcriury orc of lhe tollo*ing dftLnrions: <br />-l <br />hnvc and *ill mrinrrin rCcniltllcolConsrni t) Scl|lnnrto'for sor*cF .omFn\ oi.rslft,viicJli)rbySLttiol.l,{X)olrhc <br />lnhn C.dc. hr lhc pcrb.nnr.c ofrhc sork l'or which rhc nrnnir i\ i$ucd <br />_t h^t aod will tuinrrin sorkc <br />rhc work ror *hi.h rhh Frnrn h i <br />hy s.crion -1700 of lhc Llhor Cr*lc, for lhc I'crfqmn.. ul <br />ncc 6ni.r 0i policY numh.r e: <br />-l <br />ccnifylh,r in rh. r.rformmc of rh. wo whth lhk p.rmn is L*uc.t- I shall nol cnploy .ny lE.$n in any MM <br />so as to hconE subicr ro lnc wo,kel o iotr h{s oacalitohia. aid ng@ rhrt ifI sh.uld tEcom sot *l iorh. <br />workcr{ .omncnerion ffovkbns ol Scdion ofih€ llh)r codc,I shnll. fonhwnh .omply wilh lhos lrFvisions. <br />WARNINGT FoiluE lo suE workcd @nFnsdion 6!cB8c h !.lawful. ad shall sul,iscl M cmplovlr to rihiMl tErrlrh aod <br />civit finci ut lo orc hundrcd th.!$nd dolles (slm.ooo), ir 16 ih. .osl of comrEnorion. &mscs !s providcd 16r dE <br />Codc, inrcE{ and sltorrcy\ fccr. <br />DIq.AAAII!}N <br />I hcrchy allnd r d$ Nnaxy of pcrjurr rhur I nn li.ch*l un'lcr pmvisirtr ol'ChDlrd 9 (.on1mrc ira $ilh s.crion 70UJr 'l l)ivisnrn l <br />ol rhc ausincs\ and Phfc\\6ne c.lc, ffrl my licttrsc is io liill fora dt clf(r <br />7,/ <br />Ihcrchyllnrmundcrprnrlyofpc4uryrharrhcrcn0consrrucrionbndiosdscn.yrordct'c'om!ncor(hcwortlotwhkhrhi*rciinin <br />n{cd (Scc 1097. Civ C:.). <br />t nd(sNm:- <br />Lcda,i A.ldr.!r' <br />- <br />AITIICANL!&CLAf,.Eru.}A <br />I trrhy{mmundcr Ftrrlryofpcrjuryonc ot(h. follownlS dLtlarul 'ns: <br />Dcmolirion Pcrmirs Asrrsos Notir'rnrion l:cdcn,l Rce!lari,,ns (Tirl.,l0. Pin6) <br />R.qun.d Lrn$ol Noliltorbn <br />-l <br />@rlify rhd $c fcdcnl Eglbrions PS.rdinE &lbcslos Emrd @ nor applictblc lo lhi! Polil. <br />-l <br />ccnifo $or I htw Ead rhi! ,ppltal Erd srlrc rhr rhc at{ve in(omlion is corel I .!xc lo cotrPly sith ,U Cny and Counly <br />ordiunc.s rnd Srarc Lrws rchl ing i().onsrrucrion. and h.rcbr rlihori2. rctr.snl{tivcs olrhis Ciryand Coutrryto cnro up.n rh. <br />6ovc mnliotrcd I'b!.dy ntr insF.'i.n <br />Applicad or A!..r si8n urc <br />Appliances <br />Ivletal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />Smoke Detectors lnstalled <br />Rouqh Ductwork <br />Vents /1 <br />Toilet Boom / Clothes Dryer lo-l-lV 1 <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 />Rouqh Mech. <br />Final Test <br />Meter Release <br />FINAL lc-24'lt h14 '1i) <br />Notes, Remarks, Etc. <br />MECHANICAL.INSPECTOR RECORD <br />lnsulation <br />Above T-Bar <br />r <br />/* <br />^., 4 /zz./te <br />--+- <br />=