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DATE ID/SIG.COMMENTSAPPROVALS <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <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 rl <br />.\C\PIGType I Hood l0)u <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openinos <br />Installation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rouqh Mech. <br />Final Test <br />Meter Release -,.--\'t :.tr'*i)4 dn u)r/FINAL u <br />Notes, Remarks, Etc.tl ur <br />OIVNER EUILDER DELCARATION <br />I lrrcby aftrm undd p.Nlly of Pcrjury rhd I u credpl nom th. Co sron'Lien$ ti* for llE lollostE Easn (S€t7oll5 <br />Aueincss s,n Profcshn Cod.): Ary Cily or CNnly *fikh r€qtircs t penir lo 6nsel. all6. inl,,rcvc &mlhh or ,!rat ev <br />sr^ctuE. Fior ro irs is$8.. d{ equiEs rlE apllkd lor sh FmI to fik g si8.ed slatcmfl lhrr lE or slt is ticcneed Puls@t <br />ro rhc ptuvirao$ of 0* Conrrrcloll Liensd trs (ChaPls 9. Codftfting wnh Scclion ?000 of Di{sion 3 of llE ansin.sl 'nd <br />PDlcssions Cod.) or lhd lE oi rrE i! .rcmpl lh.Efiom ard lhc basis fo, lhe {llcgcd .r.t{,lion. Any tiolarion of Sslbn 70.1 1.5 bv Dv <br />qrplicant fot r Fmn suhFi3 llE a!0ticinr !o a .ivil p.uhy of ml mrc th.n fiv! h!.dted dollaro ($500) <br />-1.0\ <br />owncrotlheFior. t.(tr ry cnrdoycc{ w irh wrsc\ a\ rhcn $ lc mmFn\nrion. !il] do rlE vork MJ lhc {nnur ' i\ odr <br />i rndcd orolltkdlar\ c lsr...71!4. ll!{i'r.$ trrd Pnna*ions Coac: 'l tu A, rncktr'rl-i.cDscLi*dot\ndrrtflytornowNror' <br />thc u)pcny wb builds or i'npRrts rlrro{L nnn $ho docs such witrk hi'n{lf.r h.t\clior rhx'ugh his.r hcr oe. cnDkryccr. <br />frcvn[drhdsu.h iDnro\cm sm Nn intndcddol]!cd fneL ll ho(c!cr. rlEt^riklirSorimlxrc'mnris\'ld wirhi""r ]tr <br />oicomflcri(ni rh. Own$ auifis wil]hrvc lhl hunlM.flnrvin8 rhd hc.t rhc did dor ]^rild or ir9rovc tJrc politn, firrtt PurF)c.l <br />-1. <br />rsosncr.irhcpfl,p.ny,,mcxclu\i\cly.otrtsdn,g $irh lic. {d co.rrfuu nr.1,n{d.r rh. pn)l$t (Scc 7(}l'1.lltr\i .\\ <br />rnJ Pbfs\nn Codc ThcO,nlri.r,r'\ t.icon\c Lrs doc( norlmlylo rnosngofPrtNdy*ho huild\or nnProtts rhcrc.n. <br />rkl sln.ont&rrforsu.hproF-hwilh!G'nrEcbnsrlrcns.dtursrrtrrlr)lhc(]'ntJ&r'sLiccnscln$) <br />I d.rcmor nBtcr sccrrn , B. & P.C. for <br />'hn <br />Flsn <br />D.l.:- Oiftt <br />TASf,EIIi:CAMPJNSAITO]! <br />DECLAEAtrO! <br />I hcrcl,y lifirhund€r Fnalry of pnjury om oflhc followins d(l@ri.ns: <br />IrtxtrC(xlc, f(tr rhr frtunnrncc.lllt *ork tur Nlrich rhclf,nnir i\ i\{,cn <br />-l <br />h.w and vill 'Eirllin sortcr' .omFnrdion itrslEncc, &s rcquircd hy se'rioa 37m ollht tlbor Codc. for th. Ilctfotn1mc of <br />rh. wtrk lor which tth pcdir L irsEd. Mt woltss coq'cnslrion i6ur,ft. cori.r ad Fli.y rnohd @: <br />-l.cnilyrhar <br />in Ir lcrf.r@ncc oflhc wort for which fih p.rmit is issucd, I Fholl.or cnPloy any p.Bon in lnv nunncr <br />s s ro 1i..!@ subied lo lhc wo*m onPcnrltion hss olcrliloirrio. !.d dgfc rh{l ii I should $com subid m rlE <br />workc* c.@ensarhn prcvisions of Sccl io. :t7(lo of thc Libor Codc, l slEU. fonh*ith contly *ilh lhoe Pr.tisions. <br />WARNING: Fnihrc lo $curc workcr shlrcnsrk n cov.sse is uhwtul, Md shau $bJc.r cmlloys to sinin.l FmL's md <br />civil fi.* up ro orc hundrcd rhouond dollus ($IOO.O0O). in.ddnion ro lhc cosl of coml).nqrioq dero8c. !r lr.vad.n 6r rhc <br />libor Codc. inicrcs lnd arlomy s fccs <br />I hcrcby amrm undcr D.!!hy ol DcrJUry thal I on <br />.l rhcBusines ud Professioos Cod.. ud my I <br />s 9(commncing wilh Ssrion 7filo) olDivnion:l <br />t <br />I hcEb, amm undcr p.n.lry of tcrjury rnd rtFE h r <br />hsucrl (Sc 3097. Civ. C.) <br />thc p.rfinmK of rhc sork for qnich rhi\ Frnn is <br />L.dclr Nam: <br />- <br />l,ndca! Addrs: <br />- <br />AIELICANLIECIABAIION <br />I h.rc{ly anim lodcr pcnrhyofpcrjlryonc ol$c followinSdcclaralions: <br />D.mlirion Pcrmih-Ast sros Nolituatnh lcdcBl Rcglbr ioor (Tirle 40. Pon6l <br />-RcquiEd <br />(.rt r of NotifEolhn <br />-t <br />ccdil, thd thc rcdml rcsllalion. r8uding a\bcslos rcmval arc mr ,pplhabh lo lhis !mj.{r <br />-l <br />.cni[, rhlr I h.w rcdd rhis lppltal nrn dxi sure rhar rh. at w infolmlion G.o@r. L8N lo omPlv Bnh,I Cnv ind Colntv <br />odinln(r !d Srarc L!*s (hrinS lo l,u i ld ins .onshacioa un nccb, ourlx'rizc rcIrc*ntrriv.cofrhn CilvondCilorvro cntcr uix nllE <br />abovc mnrn,rcd prurerr, lor <br />)/ryTiArpliconr or AScnl SiBnrllc <br />A^) <br />MECHANICAL-INSPECTOR RECORD <br />Furnace <br />PolicyNumbcr: ExPhs: <br />- <br />I <br />=