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OWNI]I' BUILDER DFJI,CARA'I]ON
<br />I hcrcby arfirm rndcr Fnrlly ol pcrjuiy rhm l d crclnnl ft h lhc (i, mcr.s l,iccn\c tjw for rhc tolk,*ins usn (Scc 1)l l 5
<br />,lu\inc\{ ,nd Prorassion Codc) An} Ciry.r Counry shi.h t quircs I lqnir h .unstdcl. lllcr. im,'nxt. dcmolhh ar RFn r'}
<br />inuuc. prin ro irs i\{uaRc. also tcquncslnc nPpli.,nr ior such rrnrir k llL, sisncd rrarenttrr rh h.or snc ir li"n$d Pursulnl
<br />ro rhc p'ovisn l ofnE ConrE.r.r's l-ic.nscd t $ (Chdplcr 9, C.nnmncing * h Sccrion ?{X)0 olDivisio' I oirh' B$incs a'd
<br />I(nasrn)nsc( c).rrhrrltff\hc iscicnpr rhcEliomrnd Ihc h$is l'or rhr rllcB.dcxcml|bn AnyviolllionolS..rhn 7011.5 hvao,
<br />,pflicrnr tur r ,l(mri \uhjd s rhc {rlic,m ro , civil pcnally ol fr,l nnm thM fivc iundrcd dolltrrs ( $5m )
<br />-1.
<br />!\ ownd or rhc ,orcny. {,oy.nDloyces silhursc\,\ rhcir $lc s,mpcnuion. silldo lhc$1llr, 'tE(nr1m
<br />i{ mr
<br />inrctuld or oficrcd n sh lSN.?014. Burincss nnd fdnassi(,N Codc 'l hc ContacN s Licen\c bw docs .ol aPplv t' dtr owrcr ol
<br />rhcnmEny *iot ilds ot ifvtrovcs lhcN)n. d sho dms such sd. hn \clforhc^cliorrhnJrghhisorhcrot.umrlov(s.
<br />pRrvidcd rh such inlnownEnrs i( not i cndcd o.ofcEt li, srk ll k,sc!.L lh. btiklinB or inwovcnEor i\ {,kl qirhinorc rtr
<br />;L1n1{,Lri.n. rlr Owncr lluiklcr uill tnt rhc t^rdcn of Drcvill8 Ihar h. or shr dd nor tuikl or impNt Ih. lntFnv for rl. !uq$s ol
<br />l.asoqncroirhcpn)p.dr.0mcxclu\ilcly.ont,crins*irnlien\cdcotrtrrcroru.o(tudlhcp!)jsr(ss.7Ol'1.Br'i"'*
<br />lsl Pnfssi)n C.dcr Thc Conlra.ktr s Liccnsc Llu docs nor l,llly n, ttr o*n$.flmpcnvqho buildq.r nnlovc' rhc'con
<br />dnd trho conirrck rd s'chpmjccr\snhr Contrk'(9 licctr{d por\uMr tu lhc CoDua.ttr s Liccnsc l,a*)
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<br />.m crco,fl und.r sccrion-. B & I' c. t)r rhi\ rc!$n
<br />lloRKFlis' (:(tMPENs,{TlllN
<br />TIECI.A8AIIO!
<br />I hcrcby ammunncr tctrrlly of pdjury o.o ofthc folloNing decLr.Lons
<br />-l
<br />hrv. {d w irl ruitrrdn a C.nin.dc of Cotrscnl ro Scll lnruic ror workcn co'nFnsarbn, $ rovidcd nn hv Sccrb' l?00 ol rh'
<br />rjh(! Arlc. lin rhr F.rrornuncc oflhc work ror which thc Psn l i\ irsucd
<br />-lhrvcridwill.xinlain*orkc6
<br />com!'.ns0iion iflsuraE-c. as rcquito\i bY S<lnJn 17(x) oithc Lshor cod' lor thc Frrrdrmn'c or
<br />lhc work for lht hrhirF.nril is is$.rr Mrworkr{ compcisarion in surrtrc .arict ,.d Plicv nunlber e:
<br />Poli.! Numhcr:-ExP
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<br />enily rhrl in lhc !c orMc. .f rne wort lM which rhis ltrmil is hrlcd t shnll nol cnPlov anv p.son in !., m'ncr
<br />$ m b hccoR cubjdi b
<br />'h.
<br />wortc6'codp.nstrion lnss of Cdifomil {nd agEc thal if I rtould tEcom slbirt b tlE
<br />wortcu' oml,cflernrn pmvhio.s of Sccrion :17(x, of rlE L.tnr Codc l shnu. ronh*nh coq)lv wilh rho* Proaiqions
<br />WARNINC Frilurc lo Korc *orkcrJ coqtnsarion r ro aidiral lrEhi.x lnd
<br />domsls !r pmvil.d for rhc
<br />Ihcrunyalk$undcr |Et lyoitcrjuryrhdI!rliccts{lttdcrPiovi\iM.i(hrrcr9(.onnmncing$irhsN!ion?df})orDni(ir l
<br />.r rhc Busirc$ lnd Phr.s\i(trr\ Codc- oil ,y li.cn\c h h lirll lorc. mr cllcct.
<br />I h.rcby dfiro undcr Fnally of p.tjury $d
<br />isuld (sa.1097. cir, c.).
<br />io. lcnding asctuy ro. th.o.rformN orih. wort fot whkh lhis Frmit ir
<br />ra&.'!NE:-
<br />t id.l! Add!$
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<br />AJIUS,INLDEILABAfIQN
<br />I l!trb, l-nn u Mcr lEnulry .f rcrjury on orrhc foltrwinAdml ri(ins:
<br />Dcfr,lirt)n Pcflnih rhc{o\ N.riiic.lion Fcd.rrl R.SuLrnnrs ( lirlc 10.I'an6)
<br />_Rcquncd l.rrro.lNorific ior
<br />El egthrbns rcgsninB ashcsros rcmvul m .or +pli..bk lo lhh pmjacr
<br />ion 0.d ilatc lhal rnc ahovc inn,mrion is corer' I d8N lommplvwirh{llC
<br />prcsnlstivts of rhn CnY aBd p
<br />ID/SIG.COMMENTSDATE
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />lvlisc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rouoh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Range
<br />Other
<br />Hood ,i-/1Type I Hood
<br />Type ll Hood
<br />Grease Ducl
<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
<br />1,4I-u >)FINAL
<br />LNoles, Bemarks, Eh.
<br />iu,-^,etl @JIIlP'.UjraP \,p-4 grt+F-;wI
<br />It IA r*-do cyl-\I U
<br />MECHANICAL.INSPECTOR RECORD
<br />APPROVALS
<br />OlDet:
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