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MECHANICAL.INSPECTOR RECORD
<br />ID/SIG.COMMENTS OWNER BUTLDER DELCARAI'ION
<br />I hercby lrrn ond.r pc.dry of !.{!ry Ihd I m ei.hpt fron rhc Conr*ro6 Lier* Lrs for lk folloeiiS rc.h, (Se.7011 .5
<br />Aurimrs lrd Prcfession Code)r Any Cny o. Counry whkh Equirs, Fmil r. oinrud. 3ir6, i,pmv., &mlhh or E sn lny
<br />nrucrE. prior b n3 issuNc, so Equircs rhc .pplicer for such pemit ro file a siSn d sral.mfl $!r hc or rhc iq liend puMnl
<br />ro rh. Fbvisions ot dE Co.rr&mf i Li.cned trw (Chlprcr 9. Conmrcing wnh S.clion 7000 of Divisio. 3 of dE AusiM3 rd
<br />hlfe.sions Codc) or $d h. or shc b cxcn{'l ficrcfrcm $d rhc b8i! for rh. all.ged.renption. Any liolalhn of Sc.rion 7011.5 by any
<br />applicr for { ncmit suhirls tha applic&r lo a .ivil ,enalry of rct rcrc oun fiv€ hundEd doum ($500).
<br />-1.
<br />as owmr or lllc pmtEny. or Dy cmploFcs wiih qlscs ss lhct sol. coor.hs ion.willdol,f,qo mdrhe indwicmr
<br />iorerd.d or otrcrd fo. el. (sc 7044. Busincss snd Pmacssions Cadcr Thc C.htkrors Liens t w dms nol rytly h an owftr o,
<br />thc r,!I,en, *hd blikrr or in{,66 ir*mn. a,n wtn dEs Mh pon himsclf or lrr*lt or rholgh ht or hc. own.nployc.s.
<br />lrovidcd rhrr such nr{,mwnrsm mr inrodrn orollcnd for $t. lf, l5rc6, rlr hliuin-q or iiImEmfl ir $ld sirhin oE yr{
<br />ofcotr{,lcrioG rlt Oqcr Blitld will lEw rh. bldcn of pmvinS $ar h. or sh. dil ml buiB .. arpiDw rh. p$Fdy for ltE puqDe or
<br />_1. !i owtur of rhc proFny. am .r.lusiv.ly conr,k]lin8 wnn ficc.scd conrrocrm ro .onsre-l rlr pojcc, {Sec. 7014, BuilB
<br />ond hoftsion Codc: Thc Contractoas Licen* Law des nor spply ro an 6wnc, ollorcny who huilds or improvca lhcron,
<br />and who @nlBcr lor such Imixrs sirh a conado(s) Iiccnsd ,)x6unr ro rh. conrr&roas Li.!n* bq).
<br />_l oncxcrrfl lndcr Sccriod ,B.&PC lM'htrc{son
<br />l,rr( (rr.rr
<br />IOAf,EII.: TMIAIAIION
<br />DECI.ABAIII'N
<br />I hcrcby amrn lodcr F.alry ol Fjrry on. or
<br />'h.
<br />followi.g drE&,.lions:
<br />_l haw od will EElljn a C.nifi.[e of Consdr Io Sclf-lnslr for *ortcB enpe.srion. a. ,rcvidcd for by Selion 3700 of thc
<br />kbor Cod.. fd rhc pcrfomcc ot rhe etk td shich thc p6nir is hsucd.
<br />-l
<br />har lnd will mlinlaan worlcR' conp.nsalion iNuErcc, s rcquiEd by Sdion 1700 oflnc Lrbor Co<lc. lo, lhc Frfordrcc of
<br />lhc work fo, which rhis lEmir is tscd. My workc* s'nFnstrrion insuEd ffar !d poliy tumb.r el
<br />PolicyNunbar Erp
<br />-l
<br />ccrrily rhal in ih. p.rformrcc of rhc wort for whichrhis Frmir h issucd.l {hru nol c.l9loy my FMn in lny ruftr
<br />s m ro h.roft slbjc.r ro rhc wolkcJ comFnerion lrwr ot Cllitomir, .nd a8B rh&l if I shou[ ta.onE subirl lo rtE
<br />workBl @ntcnsaliotr pDtisions of S*l ion l7O0 ol rh. Ltt{, Codr. I sh,l!. lonhwilh omply with ltr$ prcvisioB..
<br />WARNING: F.ilurc lo KUrc qorkcG conD.n tun co snbjcl an cmplorr ro aiminal pcMlrics and
<br />tcoEpcrsalion, danEges as p.ovilcd for thccivil fincs ut ro oN hundrcd lhousand dolli^ (SlOJ.llX)
<br />Codc. intcrcsl and ulromy s li€1
<br />DECLAtrAIlAd
<br />Ilrcrchyilrtnru cr prnallyolpcrjuryihrr, a ritn*l undcr ttlisi,r ol chtj,s 9 (co.nmm ir8 silh Sc.rion 7lD0) orDivi\n -r
<br />ol rhc Btrsi.cs 0nd Pror'cs\io.\ Codc- md N,liccn\. i\ h lullrbRudenit
<br />CAIIIBIJqUONI.ENDIBIi.AGENCI
<br />I h.Eby !flim u!d6 FBtly of p.dury lh.t llEE k ! orsltucli,n Lndn'8 a8sey for lh. pdfru of lhc mrt for *hkh lhk l8nn i!
<br />irsed (S€c.1097. Civ C).
<br />AIPLICANL])IjIIAA{UON
<br />I lHr$y i0nD unn.r lttralry ol !.rjry onc oI rfu lollo*ire dc.lurri.rs:
<br />l)cnmlirion l,cnnirs Ashc\ros Norincrrion l:rdcrrl Rc!ulxrnn\1lirfu J0. Pnn6)
<br />R.qutcd larrc.ol Nor'fi.fton
<br />I ..niry rhnr rh. lcd.ral rcglloions Egedine dshtslos r.nuvdl ar. nor ,tplic$k lo lhn pmjccr
<br />l.cnift rhd I havc Md lhk aFtlicalion !d n.rc
<br />'h,'
<br />0hov. iniorMion h comr.l dlle roomply*nh r0 Cny ud Counl,
<br />ordinu.cs and Srar.liwr rcllri.S t)aurhotu epEer lrivcsofthiscnyaldCon y to cnlE uFn llE
<br />x,vc nrtrri{,mil ,,mP.ny hr in\F.tio
<br />Amlnrnr or Alcnr Sigidrur.l (
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Compressor
<br />Ivlisc. Equipment
<br />Duct Work
<br />Pre-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 />Rough Mech.
<br />Final Test
<br />Ir
<br />FINAL Ql2,o IK /,///Z 0)
<br />Notes, Remarks, Etc.I I
<br />APPROVALS DATE
<br />Furnace
<br />lnsulation
<br />Meter Release
<br />kndai3 AddEs:
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