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MECHANICAL-INSPECTOR RECOFD
<br />APPROVALS DATE tD/stG.COMMENTS OWNER BUILDER DET,CARATION
<br />I hcEby Dffirm undr pcMlly of F,jury lhlr I mercnfl lbf, rh. Crnmdoa Ltens. Ltw f6r rhe followi.e rclsn (Se7011.5
<br />Blsiffis !d Prcfcssion Cod.): Any Cily or Counly whi.h rcquiB 3 Fm'ir lo conso.l. dtE. imrmw. d.mlnh or rcplt ey
<br />sm.rue, |ri6r ro its hsuse. al$ icqun s thE spplicanr for such pcnir ro ,iL ! si8ncd sllreft rhor lE or shc ir licci*d pomanr
<br />lo ltc Fovisioos oa lh. Conhcloas Li(ned t w (Cl'aplc. 9. Commmin8 wilh S..lio. 7000 ol Divihn I of lh. Burincs .nd
<br />Pmfcasions Codc) orrhar h. orslE is cxcm rhdtfronand rhc basir aor lnc .8cn.xchption. Anyliolationofsdtion7011.5by3i,
<br />applter fo, { pcmir sbjccls lhc {pplicant lo a civil p.Elry of tur tur rhu fivc huldrcd doll&s {1500).
<br />-l,
<br />as o*rcr of rl* proFny. or my cmployes wirh wagca 0, rrEn $k Nml,ensrbn. wiu do llf, wo* s,i rl* slrxlN is mr
<br />inre,'d.tl or o,ftt! tor slc (Sa.1X4, ausimss md Proacssions Cd.: Th. C..lnclor's LtcnE L8w &Es ml lrrly to d owrcr of
<br />tho rmp.ny vts hdild. o. in{mws 0E6tr trd who des rkh e* himsclf or hcFelt o, rhoush his o, lEr own co0loy.cs,
<br />provid.d rh skh inrm1tftflrs re d inkndcd moficEd lor et ll howE, rlE tuitlin8 tr inrrmEftnr Ls s! *nnin oN y@
<br />o f cor{,hlio n. lhc Ovncr Buil&J will hns tlE budcn of povinS ln3r tE or sh. iId rcl brild or iq'mrc E l,mFny ror thc puqnsof
<br />-1.
<br />N osncr of lhc [or.ny. sm cicllsively conlEcl in8 wilh liccnsd contrctor to construcl lh. pmjd (S(. 7044. B6insr
<br />ond hb(\sbn Cod.i Th. Co.rocroar Lic.rsc taw docs nor aDplyro m os@r ot p.opcny who blildr or inpreki rh.rcon,
<br />and sho onlmcrs ior sucn !,oJc.ls qill' r Conlnctons) licnsed putru r ro rlrc ConrR.tols Liccns Law)
<br />-ld
<br />cxchfl lnddrS6riotr-. B. & P.C forthi!rdson.
<br />WORI(ETS' COMP'NSA'ITON
<br />DEqdAAItaN
<br />I hc,chy rfiiirnlndcr pctrohy of pcrj!ry onc otlhc aollowinS d(l.rorions:
<br />-lharcu
<br />will rointrh a Crnificrlc of Consnl x, sclr.lnsnrc rur wortcB ompcN0rion. as a,ovidcd for by Sr..ln l7rx)olthc
<br />tjhor codc. ror rtu n nnrnm.c oflhe sork lor Nhi.h rhc ps'n ni\\ucd
<br />_lhave ond will mrinroh workcB cornpcns ioninsuruncc.rs rcquimd by SR! ion l7m ol rhc Libor (lldc, lor thc pcdonnrmc of
<br />rhe voi( rar qhich lhis Frmil is hscd. Myqorksl compctrsrli,in insurntrc conicr dxl Foltt Nmnc. r€:
<br />c.,,". . 5ltqt€ c9NPeq*,+ion
<br />OC ., - tzlvlie
<br />_l c.dityll.r in rhc lcrtormtuc of thc wort for whth rhh p€rnn is is.u.n.l shall not cmphyaorrccon in any tunmrs alo tE om subr..r lo tlE m*ds onqFnelion l0$olc.lil6hi!. and agrcc rrd ifI should tr.om subiet io llE
<br />wortc^ smp.nsdio. lmvisions of Scclio. l?u) ol lhc ldbr Cod.. l dtsll. fonhwnh omply wnh rnoc pmvirions..
<br />WARNINO Failurc to w!rc *orkcrs conlrcnslion ovc6e€ is uakwtul. nnd shlll subJ..l !n cmplorr lo siminol ltMlltr ond
<br />civil finc\ !r lo onc hundred lnousnd dollor ($ld).000). in eddilion lo th. cost ot comnc.salioa, daruscs as pn,vid.d for lhu
<br />=?
<br />LIcEES[DiOlr&tCrltB
<br />oEct4BA.UlU
<br />I hcrubyaitnundcr pcftlry of F.rjurr rhd l0n liccnsi lndcr provtion olChnprcr 9lcomtuncins sirh s..rii 7ux)) orDivkion:l
<br />of lh. B!\inesrnd Ptotc$ionr Gdc. ud mrliccn* h in tull fotoT uxj eltNr.
<br />'.loYt55b. Al?\tit
<br />!aTi,Ii1BI(IIANTE!DINjj.A1iII!!:I
<br />IhcrchyxllirnruDdciFnrlry.ll)crjuyrhnrrhcni\rcoi{ru.rionlcdingtr!.Myr.rrhcNrtonn.ncc.lrhcwnrkrbrwhichrhnpcrnriri\
<br />i\\!.J rscc :lrD7 (-i! C I
<br />AITLICANLDIILAa]IIM!
<br />llElty dlinnrndrr ncnrlry ofncrjury nnc ofrhc foln,winr dcclarrrn,ns:
<br />txNnirior PcirnirsAsh({os Nolifi.ati.n rrdchl Rc8uhrn'n\ (Tirlc.l0. PM6)
<br />Rcqxncd Lcrrq ol Norifi.di,)n
<br />-l
<br />ccni{y lfilr rh. fcdenl rqrllrions Egedins Nbcsros rcmvol arc nor amlicable ro rhh orccl
<br />6l anify rhlr I havc Ead lhis 0lplicarion anl srob fior thc shoE informrion n corE l. t aEN roomplywirh lllCiryand Corory
<br />ivcs orihis City rd Counly lo cnls uron ltrordin0mcs.Ni Sldc lrws Elnlin8 ro bu ildine con{flcrio( and hcr6y_,lr&1p.n**nuohov. mnliomd pmFny for nr{Erion purF*s
<br />Appli.anrorASc SigMrurc
<br />e".,r,* -* ro,r"r, )( oiklo Shprhori
<br />6/zil lE
<br />Appliances
<br />l/etal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />lQpmpressor
<br />Misc. Equipment
<br />Pre-lnsulation
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rough Ductwork
<br />Toilet Room / Clothes Dryer
<br />R esidential 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 />An)
<br />Rough Mech.i (lr{ (i ,r$rtlr/
<br />Final Test It ol
<br />Meter Release
<br />FINAL 4t\ER'to xmZ.:,'r9)
<br />Notes, Remarks, Etc ul
<br />Duct Work
<br />Vents
<br />Sr*rion 3076 or ihc t ifl Codc. intcrcsl and ltromy s fes
<br />"",,'SlztliE
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