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MECHANICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUTLI'ER DELCABATION
<br />I hcbby llfm undcr p.dlty of lx jury rh.l I d .rcmfl fmm rlE C..hcroR' Li..M h* for lhc fouoqing M$n (5...70:11,5
<br />ansin ss ud Pbr.sion Cdc): Any Cny o! Counly which Equircs a l'cmil to 6nsmd. ,lto, ioprorc. d.m,ish o. EP8n 0n!
<br />{ d@, Fior ro irs kurftc. trls Equn s rhc rpplicmr ror such lErmir ro filc a sisrcd sralcmnr rhar lE or sh. is liens.\t pur@l
<br />ro rhe ltulisio.! oatlE Conr6loi. Lk.isd kw (Chiprr 9, Conmftin8 wi1n Scction ?0m of Divhion I of llI Burims altd
<br />Pmtcisions Corlc) or rh.r lf, or rh. Ls cx.rpl rt rchon .nd rh. bcrir for lnc llEg.d cictrrplion. Any aiolrlhn of S6rb. 70:l LJ by any
<br />applic. lor a Fmit subi(u thc lpplicant lo a civil pcnalty or nol mr. lhd fiec hundioj d.Ues ($500).
<br />-1,
<br />!s o*ncr of rhc ptoFny. or mt cnployccs *nh *!scs &s rh{t sk conIEn*tion, wil & llf, wort si ltE sltui@ t er
<br />i,ncftlcd or orcrcd tor elc (Se 70{4, BuiiErs dnd Profcsions C6dc Th. Conlraclor's Li.cnsc Low does nol arDly ro a osncr of
<br />ih. pmr.ny wh t[illls or inrmws tlEstr !d who dssst s him\clf or hcr{lfor thsu8h hk 6 hcr own cElloyNs.
<br />pbvidcd rhd s.h iqrcErnts @ ml i.lcn Ld oroffcr.d for sk. Ii how.s. tlE hrihins or ilf{@tunl is $U wirhin oR rau
<br />ol oryhrion. thc O*mr BuiEcr *all hlr itE burdcn .r F.ving rhd hc or sh. did mt ttrild or inrmw lhe Imrsr, aor dE Irrlbs or
<br />-1,
<br />us owncr oa lic pmp.nr. adcxclusitcly co.[&ri.g wnh licen*d codr!.roa
<br />'o
<br />@n(Ncl llE pmFcl (Se 7044,8!!iEs
<br />and PDE ibn Codc:'lh. Conlfurol* Lic.nrc Lrw d.cs nor at l,ly to anorncr ofrrcp.ny who bualdg or ionovcs lhcrcon.
<br />lnd *no conrmrsfor such pDjecls wnh ! Coffradod, ltcnrd pllr@r roth. Conlr.ddt Lic.nsc L!w).
<br />l amcrc'nn! undcrserion .It & P.C. f.r lhn rcJloi
<br />l)lt€: Orrer
<br />II)BSE8S:.GI}MfjNIAIIIIN
<br />DECIAM:UON
<br />I n rcby aifirm undcr Fndly of Frjuiy om of th. following d€horio6:
<br />-l
<br />hav. aM*illroinrdn a Ccniiicarc ofcons lo Sclf- l nsur. aor workcs compensat ion. s provided fo r b, Sec l io, l70O o f rh.
<br />t ho, Codc, fo! rhc Frfo1lree ol llE po* lor whict lhc pemn t i$!cd.
<br />I h6vc rnd will m0inl.io workers compcnsution inslBncc. !s rcqlned by S(ltun l?m ofrh. L.bor Codc. fo! rhc Frforroncc of
<br />rhc work r'o. which this permil is
<br />/--d
<br />sorkcB' comn nst,n insxr0ncc.anic. ond plicy numbs Nl
<br />t-a-/,/ <->7rc
<br />-,
<br />srrily lhrt in rhc lcr,'onunce ofrhe worl for which rhn per6i! is irsucJ. I sh.ll.ol cmploy an, pc6on in atr, man..r
<br />s &5!o l$m s!b.i(r ro rhc wo*6'm,ntcnslbn laws olcnlilomia. and a8E th.t ilI snould lt .ft brcr to lh.
<br />srtsl omi,cnsliotr I,DvhioB 6lsccio. lr00 ol thc Lrbo, Codc, I sh3ll. fonhrilh comply wilh tho{ povi!i.nr..
<br />WARNiN(;: Failur. i. suE sorkcs conqEnslion covcEsc k unlo*tul. aftl shall sublv m coplorr to siminll pcMtis ald
<br />civil fin.s up ro om hrndr.n rhousfld dollaa ($100.0mr. in oddirh.lo rhc.on otco,rF.$rion. dlm8cs as prolid.d lor thc
<br />Lrc[N$tlcqNl&ul!)B
<br />II}:ELAAAIIAN
<br />I hcrchy rfi,nlndcr pen yofp*jurythdIa'nliccos{undcrpmvisbtrolChrIcr9(conntncingsirhScdion70(xDolDivisionl
<br />of rh. Busincs\strd Ptr,fc$nrns cinh. rit mv li..ns. i\ in fullfore dcllc(.
<br />C a aA 77s<
<br />L.or**-
<br />cortsTRucrloN I nr{nlNc AcFNcY
<br />I hcrhy amrn undcr p.Blry ol r.rjury lhar rhcrc is a 6inn rion lc.din8 leercy aor llE ,.rf()l]rl!re ol llE wdt for {hkh rhh Ismn i'
<br />is.ucd (Sft. 3097, Cit. C.).
<br />affucatrfD[cl,A8auoN
<br />I llrt y onin, undcr pcnlll y ol pcrjury onc.lrh. ri,lLsins dtl,6ri,,'!
<br />Dcftliri(,r Pcirnik-Ashc(os Nolilic0rion ltdcr0l RcEuldions ( lirlc40. P!n6)
<br />-Rcq!
<br />ncd l.ncr ol Noriarculio.
<br />-l
<br />.cnify rhdr rhc fedcrll rcgrrlarions rcE,rnib8 lslEsbs Emovll d nol arplicablc 16 lhis ftojccl
<br />l.cniiyrhar I hsv.r.adrhisc!'tlicarion{xl (urcrtd fic atnvc infomlrion is cotrc.r I rBN lo onpl, wilh all Cil y lnd Cou.r,
<br />ordinanccs lnd Sr,rc ti*s EbriiC ro building .on{ociion, ed hurcby,xrhorizc rcprcscnlrlivcs.frhh Cily and
<br />lhrvc n*nriomd lropcny 16r i"sp..' trn ruio)xci
<br />An.lic,nr or Alcnr SiemrurE
<br />,/g
<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 />Rouoh 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 />Openings
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.
<br />Final Test
<br />Meter Release
<br />FINAL
<br />Notes, Remarks, Etc.
<br />Furnace
<br />lnstallation
<br />-
<br />I
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