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MECHANICAL-INSPECTOH RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWIIER BUILDAR DELCAXATION <br />I h.rcby affm un<lcr Fnalry of Frjury lh.l I M .x.npl 6om thc Coirr&lor' Li.c.€ tj* for ll* lollosirg ts. (Sd.rall.5 <br />Businc$ .nd Prc&ssio. Corb): Any city or co! y *hbh rcluncs 0 Frnil lo onslMl, ,116. inlpbve. &mlish or q)on !n, <br />dcl@. prid r. ils isslaftc. lho BquiEi $c lpplicul lor such lEmir to ,ile a siged .r.tctrd tnll lr or shc k liccnsd pumml <br />ro rhc Fov'eiotrc or rtl Conrrsrols Lic€nsn k* (Chapr6 9. Collremine wnh Sslion 7000 of Divhion 3 of llf, Blsinc$ dd <br />Prof.ssiors Codc) or rtar hc or slE i!.r.nq thdctom md th. bsis for rhc alh8.d .xcmplion Any violdion ol Sedbi ,011.5 by any <br />dpplici tur a D.m slbjccls thc oDplicrfl lo ! civil pcnllry of nol m.. lh.r fit hrodtd dollaa (i5OO). <br />-1. <br />n{ o*rr ol lh. Iri,rrny. rtr rycnlloyccs *nhwrsc\ r\rltinnccolnr^-n'rri({. qilldo rtr $rk lld rh. { rurci\nor <br />inrcn{ld ornncr.d l(tr *rlc (S!!.71).1-{. Bu\ir.$ itrd Prorcs\n,n\ C.x].:'Ihc c.nhdntr s l,lccn* I-ow docs nol {'!ly ro !no*ncr.l <br />rhcpm!.ny shohuiil\ori pnnc\ rhcRD. nnd $ hu d(ts \kh \ od( him*ll or he'\clf or ih(,u8h hi\ or lE orncmplt,yt.\' <br />IroriJctl rhxr \u.h nnpn*rmnh & nor mrcd.\l or ollcrcd li)r sL li ho{crcr. rh. huiuirg .r iqnort,Enr i\ w,U $irhir <br />' <br />{'. }tr <br />ol nnntlcliofl. tl[ Oyncr Buiilcr sill hdvc rhc htrrd. oftmrir! rhdrh.or\hcdil norbnild ornrpntrt rhc Pmnrtry lirrltl !rr*ol <br />-1. <br />ns owrcr of l hc pmpcny. ad .r.lus ivcly .onlr.cl ing v in l ianscd co dcroB lo co.sdcr ilE P,ojccl (Se.'7044 Businc$ <br />ad hstusid Codc Thc Contrclor's Liccn\c tjs docs ml tptly r. ownn olnropctrywho huildr or inrorcs thc.co.. <br />3rd vho ontets lor .Eh pmj.{u wilh a Conlmclo(, li.trsd PUB@d io rhc Co.lt.crols Ltcn$ tlwl <br />-l <br />ah crcmfl lndcr S6rion- B. & P.C. for rhi! reason. <br />-thNcndwill@i.r,uoCcnifrcltlofcons <br />h S.lf lnsut fot workcs smFnsrion. &r Fnvidcd lor bt SNtirn l70O.{ rhc <br />tibor Code. tor rhc lcraorn1am of rh. roll aor which lhc p€mn G L*!cd. <br />-l <br />havc a.d *ill mainkin vorkcr' comp..s{ion i.sunncc. as rcqltcd b, 56l ioo l70o oi lh. L.bor Codc. fdr $. pcrfol1mc of <br />rhc sork for *hich rhisp.rmir irirsrd. My conpcnsliotr ins!6B.n rhmrn Fniy nunficr e <br />-l <br />*rrify thll in rh. tldtomrc ol0r for whi.h rhis ncrmir ir h{kd.l rhall no!.q,lo} My peson in an, nEnncr <br />s N ro t8om suhiri b ihc worksl coqrnsarion bws or Culiromh. ond 0gN lhor if I rho{B b.tom subiccl lo rhc <br />workcG corpensarion peisionsofSection 1700 oflhc Llhtr C.de.I shsll, fonh*ilh condy wirh rho$ pmvisio,s. <br />WAININ(; F ih,rc rn wur *orken <br />civil fi.cs up ro om hundrcd ln.usod <br />..mp.n\rrion n,vcr,0c t u.huful.lhrll subjccr an cmplorcr ro miindl Fmhi.s !trd <br />compcnsolion, damscs as trorid.d for lhc <br />-t <br />serion 10?6ofrhc Lit r Codc. <br />UIENUiD1.ANIEACI!)B, <br />DICIdBAUAN <br />Ihcrchyaffirmundc.nnlhyotp.rjuryrh,rIa liccnscdundcrpoltion.rchqrls9(connncnci.ssirhsc.riun7u )olDivision.l <br />.r rh. auj'tr.\rnd Pr.lc{.nn.CrJc. i,il n\ hccnq ^ 'n <br />lulllhr(rrlcltrtr <br />to u (t <br />C0NSIAIJI]IIOIIIENI2INCTTCENCI <br />I ltrchy rifinn undrr pcndxyollciury lhrr lhcrc n a con{torrion Lndir{ r!ck-.} i,tr llN pcrln'nuncc.rrhc work tu which rhn Fnnil is <br />is\ucd rse 1097. civ c It nddl N.rc: <br />- <br />kdcr'r Ad.tB* <br />- <br /> PPI ICANTDECI RATION <br />I lErcby nlllnn uRlcr pcnxl'l ort).rlury on. ol rhc hll(N'inr dcchrrri.n\l <br />Dcn$lirion Plnnirs A\br*os Norifiqlio! Itd.ralRtSUhri{^ (r h.l1r, PfO) <br />Rcqutcd Lcncr ol NoliIc,ri,m <br />I .cnify rhat rhc icdcnl cgrlario(s E8lrning astrslos rcnmvll &c nd dpdiablc b rhis pmj.{l <br />-l <br />ccd ily rhr! I havc rcrd rhjs .,rplicdli6n dld naic rhd rh. lhovc inturrorion is.odcr I !8rN ro coq,,y lilt allCry rnd comty <br />odinarccs and Srllc trws EldinS ro nu .onnrudaotu dd hcEb, {urlbrtc Epesnfiiws ofihk cilyad countyro cnld uFrn 0E <br />ntx'lc trrnri{,rJ J,rcp. yntr <br />Ap0licanl or ABctrt Sknalu <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 />Rouqh Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <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 />Above T-Bar <br />Rouqh Mech. <br />Final Test <br />Meler Release I <br />FINAL 4h1lt1 n iz!'f4 a7)r) <br />Notes, Remarks, Etc.U I <br />D.le: - O*t.. <br />wonxens' cou iinrlilrlor.r <br />DECLABAIION <br />I hcrcby.ifi rmlndcr p.nxhyorFrruryonc of thc fdlowiry dNhra'ions: <br />.\P <br />N d./8 <br />lT <br />I