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MECHANICAL.INSPECTOR RECORO <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCANATION <br />I h.rcby affirh lndcr Dcnalry ot |lc.jlry tal I d.xenq lon thc Co trlon Lltns Li* for rlE f.h$ing..ssn (Se.7031.5 <br />Buinc$ a.d Prcr.sion Codc): Ary Cily or Counl, qhkh rciuiB ! lrrnin ro sislmr. rllr. ihpmvc, &mlsn or c,uir ey <br />srncluc, prior lo ns iss!ffic. ah. rcqnarcs rh. trpplkanl for such Fmil to fi|. o siSncn slalcmnt rh.r hc o. $c k licnsd puN& <br />lo lh. !revkions of llE Conltultr's Lic.n*d Liq (Chsrlcr 9. ConmBine wnh S.clion 7000 ot Dieision I ot rhc Blsircs .nd <br />PDlcssions Codc) or fiar tE or shc Lr .xempt lhcrclion dd rhc buris for lh. sllc8pd.icmttion. Any {iolalion ofscdion 7011.5 by any <br />apllicafl for e pcmn $bj6l3 rlrc applic,nl lo r civil p.nllry ol mr mrc thM fiv€ hu.dcd doll4r (t50o). <br />-1. <br />a\ ovncr oflh. poFrly, or my cdplortcx wilh wag.s !s lhcir $lc @npcoslio., will do tlE *nk ud llE smrd@ Lr ml <br />inrcn Ld or o,Iern for sh (56.70{4. AEircs Dd Pml6sl,6 Codc Thc Conlroclols Li.eM tis d<xs mt q,Ply lo u o*ffi of <br />th. tmpcny who builds or inproB dE6n. and vno des sch mi( hih*lf or hcAdll ot thrcu8h his or ncr o*n cmployccs. <br />Fovid.d lMl such inpro@irs E bl i tudcd qoflcird &,r sk.lr.lFwE, itE hildinS m inPoEmrl is sld *irhin nm rE <br />ol complcriol rhc Owsr Buitl6 wil hrk thc burdcn ot prcvitrg rhll tE o. .Jc dil ml boild or inpmw th. ,)sl,6ly fd lhc ,,urpo* of <br />-I. <br />ds owrcr ordc pmpcny. om crclusivc!, .onroci ins silh licn$d .ooitmroF <br />'o <br />con$ruct lh. pmttr (Sa. 1044. Busoc$ <br />aln PNtlshnCodc: Th. Cont roa s Lic.ns. kv docs mi atlly lo sn owncr of !,opcnr wll(, builds or inpmvcs rhcreon. <br />a.d who codack for such ,,ojccrs with o Connmrn(s) li.ln*d plFunr ro <br />'hc <br />contrclols Lkens Lrw). <br />I rmcxcn.r undcr Sarion .B &PC fo,rhtrcr.on <br />Drr.r Orn.. <br />IOBf,E8S:.CI}IIfjNIAIIAN <br />DEqABAIION <br />I hcrcby al6rn under pcnllry of rE jory om of rlE following del4rdrbns <br />-l <br />h0vc ud $ill roinrnio ! Ccn i6.trr. ol con$[ h scll: ltr\uic f{tr sorkds conll].nlarn]n- ai Forid.d f.r hrsNrionl?0Ooflhc <br />L'b{tr ( odc, lnr rhc lcrl'oflromc of rh. Nolk rd whi.h rhc p.rnrir ir ksrd <br />-l <br />h!!e and s ill dainraio sorlrc compcnsalion insumncc, as rcquncn h, Scct ion 1700 of lh labor Codc. for the I'crfolrr@. of <br />4 ACN cMrcv) <br />S <br />-l <br />enil, lhol inrh.lErlormneof lnc wort for vhich lhis pcrm iiLi cd,I sh,ll not c'nploy any lc6on inrnymnncr <br />s N ro tEcom rubjer ro rhc hrtas ooFnstion lows ofcditomi& and r8rcc lhIt if I slhlld b..om lubid b tlr <br />*o*cs on\Tnsolhn rmiiiionr olsecrio. lT00 of rlE Lihor Cndc, l slEU. fonhwith.omlly eilh {h6* t Dvisions.. <br />WARNINC: Fail@ ro scurc sorkcrs ompcosstion covcn-qc is !nla{t!1. and shnu aubJ.{ m cmllorr lo riminal Fmlrls and <br />cilil linc\ xp b onc hundftd lhousrnd dollaK ($10o.(DO). in ion ro rh..od or.o'nFnsrlion, dlluses as pr.vidcd tor rhc/;zu2a/av <br />DICLI.SAIIO! <br />I hcEhr rrfirh und.r NnrkyorNrjury rld I rfl lianed undd !rcrision olCh!flcr I (.onNncin8 sirh Sccrior T(i(x)) oroivi{ion:l <br />of rhc Bu\i.csseftl Pmlc\sion\ Codc, sl mt li.cna n ir tullli)rc. d cll(l <br />b g? <br />I ncEby (mirnuRlcr pcnolr, ol!.rjury ih,r 'lu. isa cotriru.riotr htrdir8 oscm, f{tr lhc p.ttortuftc.lth. work lor $hi(h rtis penlir i <br />i\sucd rS... l(})7. Civ. C.) <br />AITU(ANLDECLABAIIO! <br />I lEEty lilm rndcr Fcilhy urruriury onc olrhc loibwirs dalrlriqN: <br />D. n,liriotr PcflnirrA\hcnos Nolilicalion fcdcralR.Coldn,n\ l'lirl. d0, PM6) <br />-Rcquircd <br />l.(cr 6f Norili.arion <br />_l ccdify rhut rhc t dc.rl rcauhtions rcSardinB aslEsl osrcmvil c nor lpdkabL b thN prclRt. <br />h. trthvc nrfonmlion is corccl I uErE lo Nndy wirh all Cny a.d Counry]ll.d,ryrhd, hNc rcrd rhr JIIINd <br />ii^l'nzn.cs snd SrJr. b\\rcbrin!ro hui Eprsnrrrivcs oflnn Citydd Co!trryro.nr( uFn tlE <br />$ovc rcnriokd pDl.ny r(r nNrsrio <br />Amlicntrror Agcnl Si8n rc ac- <br />x <br />'4.--".. 6-+-oc-rg <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 />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranoe <br />Other <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 />Rough Mech. <br />Final Test <br />Meter Release <br />FINAL <br />Notes, Remarks, Etc. <br />-, <br />Hood <br />C.dc. inlercsl otrd oltomy\ {es <br />Diie I <br />----+--- <br />[T