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MECHANICAL.INSPECTOF RECOHD
<br />APPROVALS DATE ID/SIG.COMMENTS OWN ER BTIII-I)EII DEI,CARA'TIoN
<br />I lNrchy trlltr lftur prulry I p.rjury rhrr I ar crrnw rion rh. Coft,.l.s Liccrsc Lrw tl'r rhc lollowin8 rcNon (Scc?0115
<br />au\i'i.\\ nlld Pn,lcsri(,n Cnl.J: An, Ciry or County whi.h rcqtrnc( ! r'crmn h con(ruc|. rhr. impn&. d.nioli\hlr rcFn Jny
<br />{nrcrurc. nriorro irs isnmncc, lko rL.qun rrhcapplicur l'.r such pclmii k, tllc a si[md nrhnrnr rh{ hcorstu is li.ctrrd pursL(trr
<br />r. rhc IovisnnF olrlr Co0tr.rols l-iccn$d ljl lch.Ircr 9. ConrnErrir8 wiih Sccri$ ?(XX) of Dililbn .l of rhc au\ino\* rnd
<br />l'rolcssi,rsCodc)orrhxr h.or\hc i\cirmfl rh.rcfrorand rhcba\n ntr rhc rllcgud cxcnlniur. Anyviolnti.nofSccri,r?0.1156y!ny
<br />it,rlicr ,nr, I,ooir\ubrc.r\rfu rmlica.' ro 0civill]cntrlrrornot morcrhrn fivc hu rcddolklSsU))
<br />-1,
<br />as o*id of rh. ,,tu,,cny. or ny cnl|rlorcs wnh sages $ rhct ek compcn$rion, will do 0E worl !d tE nnmft is nol
<br />iircid.<l o.offcrcd lo, eh (Se.7044, Busimlr.rd Prof.sions Codc T,Ec.nlrsclols Li{nsc L€s &er Nl tflnyro osrcrof
<br />rh. tmt'.ny wtn tuilds tr irq,mE thc@n. atd wlE dG s..i wlt hin$lf or hcrsltor lhough hi. o, hcr ow. cmploFs.
<br />,mvid.d rh{ rrch inFDwdi @ mt inlcidcd oronlrd for sle li hosw. dE tdildi4 tr iqnMdnr k sld *irtin on. Jt(
<br />of mq,lcrio'! llr Owfti AuiBr will how rt! h!rL. df |,lvin8 ${l tE or rh. did ml toild d i,F.!w dE p6Fry ror llE po4xe of
<br />-1.
<br />a\6wnrofrh.!q'edr. merclurively.o.E_dcling wirh lien*d.onrdcron to o.slrucl r,,!j.rl (Sc.7044. Blsincs
<br />ard PDftssirn Codc: Thc Conlrsror's Liccnic ku dc mr lFply ro otr owner of propdry $ho buildt.r itrmvcs rh.rcon.
<br />and who .od@rs for $.h |l()j.d. wnh ! G)nndcon.) licned pursu.n' b thc Contetols Lt.tr* Law).
<br />-l
<br />m eicqr undcr Seiio.- B. & P.C. for lni, rcdon.
<br />lll8f,E8s:C!)!4rBtArl0tr
<br />DECI,ASAIIq!
<br />I hcrcby .tfirn undd pcnalry ofp$iury om of lhc following d.cknliom:
<br />I;'hr Oxl.. fir rhc lf,rlomuNc ofrhc $ork lnr \hl.h rh. Fnnir tr tr{rcd
<br />-l hav. and will ruinrsin worlcs .onqxnsolion insunmc. !s rcquncd by Stlion l7m of rhc Lrho! Cod., for th. pnaotlMc. ol
<br />ihc work ftr *hti rhir Frmil is h$cd. My workds compcnsolion imurmc €Micr en loficy nlnbcr @:
<br />-l
<br />ccnify thal in the pcrlorrorc ofrh. $ork Lr qhth rhis Frmir i( issucd.l sh.ll nol cmployatry pcr$n in any manncr
<br />$ !s ro tEsm rubjd r. rhr w.rlGs .oop.nsa(ion lnws or Calaromh. .,rl 38e lhol if I shoukl l,ccom slbixl ro ilr
<br />so.lm NBlcn$riontovhbns olsdion 1700 oi rhc L.trr codc.l shnll. fodhwirh cory)ly *irh rhorc lmvhioni.
<br />WARNIN(;: llilurc ro $cur! wortcu dnhpcnsdion cokrrEc is unlawhrl. ond sh.ll subicr on mrlor. to rininolFnahtr ud
<br />civil lincs !p ro one hh{,icd rh.rsn<l d.U!F {Slm.fin). in addirion ro rhc.os of comlcns.rion. drmEcs 0r I'ri,virtcd t* rlr
<br />SR_lion 1076 ol lhc Llhr GrL. imcrci and anorfty q rtcs
<br />d-(
<br />I hcrcby ulrirm uMc, lcnollrofpcrjlry rhd I Mr licnwl undct orchrpr$ 9 (omarn.inS wirh sdbn 7(x)0) ofDivi\n,o l
<br />ol lb. ausimss and Pmfcssn,ns Codc. {'d ny li.cfls n in tull fore nd cfld.
<br />CANf,If,!ICIIONI}:!!I!CJ!DNCI
<br />n\ucdls.( l0i)7. cn. c )
<br />AITLIIT TL!T:!LI.8T[ION
<br />I trruhr rlltD rRl.r p..nlry.l Nrjury om olih. tulIisi',9 Jc.h.rri,na
<br />l).nnirn,,Pc'nrir\ A\}inosN rifi.rrin tcdcrnl R.!uliri(trr(Iirlc J0. Pin6)
<br />-Rcrtun.i
<br />l-crrcr I N.rili$rion
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rouqh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Range
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />Openings
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />lr
<br />Rouqh Mech.il I If4 Ailltotrr (61)
<br />Final Test
<br />FINAL \11 vvlAh/ltlh K//
<br />Notes, Remarks, Etc
<br />Meter Release
<br />t de Or.erl
<br />PolicyNu rlu
<br />-lirttcsl
<br />t n<t ii Mre:
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<br />L.nd.r'r Addrcsr:
<br />-
<br />-l
<br />c.d ify rnd rhc f.dcial e$,larionr Ega.di.e astr$os rcmval ac nol lpplicablc lo lnis lrcjlIl.
<br />I edily
<br />'h!'
<br />I h!v. rcnd rht nrrlicalhn!d
<br />oklinrnccs rnd Srrrc IiwsrchrinS bhuiklinE
<br />lhovc mnriomd !fl,pcn! for )'zX'tE-
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