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MECHANICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I h.rcby atfrm u.dr Ftulry of Frjury rhar t u cxcoo ton rhc Co.Eaclo6 Lietre tlw fo. rhc follosi.e G&r! (S6.70J1.5 <br />Busin.$ &d Profc$ion Cod€): Aiy Ciry or C@.ly whici EqriEr . p6mjr ro @GtBct. .hE. iq,rew, dcmli{h or rcpri uy ' <br />strucnE. rior ro irs hsu.m. de EquiB thc lppli:ot for skh pcmjt ro fih , siEmd sllrcmnr rhar lE or sh. n liccr*d pum r <br />ro lnc pmisions otilE Conr@t6. s Liensd tlw (Cftr0rd 9, C6nmtuing warh Scdion 70l|(J ol oivision 3 of the B*incss rnd <br />Pofcsiois Cric) or lh8t h or stc h .rcq,l rhcrcfroo arld lh. hdsis lor $c rlkScd cxcmptio. Ahy viohlion of Scclion ?011.5 bt lny <br />applica.r for !p.mh $bjds rhc lprlks.t lo a ci !I,cnatryofnor mErhs file hudEd doll&s {5500), <br />-1, <br />!s oqmr of thc pNrcny. or ny cmDloyes qiri lrl3es !s rhct $lc onpcn$rion, will d. dE wori .id rhc slulw is mr <br />inrcnicd or o,rcrcd r.r sL (Se.7{}44, ausiftss and Prol6sions Codc: Thc Conr,ocrois Ltcns. ll* docr @r apply ro a. ownr of <br />Inc rmrcny who l,ti[:ts or ituphB tlE@n. !t eho des su.h m* himclr or h.rslf or llmugh hh or hcr own enployccs, <br />0rovid.d !h!r skh inprcEmnlsmmli..dcdorotfd.dloreh lf. homiq. tr hoildine or in{mwmm Lq $ld wi6i. om )ea <br />of cotrpklbr llE O*mr Buihcr will h!rc th. bunhD of prcvin8 Uut h. or sh. dn d boiu or inproE re pmtEly fot lrE [orFs of <br />l. dso*mrorrhc pmlxny, dm.r.lurivclyconrd.rinB wnh U.c.scd sntac roN ro co n( rucl lh. pmlcd (Scc. ?O+1. Busrc$ <br />ond ltDfGsion Codc: Thc Conlncrols Li.cnsc L!* dcs nor applylo moqncr orpropcny who builds or impnr€s IherNn. <br />,tu1 who.$nlh.rtuslchrmj.ctwnhnCoorEcrDrls)liccnsdI,unuonrrorhcCod6d6asLi*n*Liu) <br />-l <br />m erenfl lodf Serion-. B. & P,C, for $is E.rn <br />tva.8f,Ef,iraMtrNt rl(N <br />DECIABAIIOI! <br />I hcnt y llnrmund.r pcnally of rErjury orc olrnc lolbwnrr d(lrnrn,N: <br />-l <br />lEw sn will minrlin a Ccnifrcrtc of Co.Fnt ro Sclf'lns!rc fd qtrlds onpcn$rion, s tmvkhd for by S6rion !700 oflhc <br />Lltor tuc. for lhc PcrfolMa of lhc mrt fd vhi.h Ih. Fmil is tsd. <br />-l <br />hat .nd will mainlain wortcn cum0cnsrnm insuErcc. &s ,cquircd hy SNr io. l7{D of lh. rjho. Codc. lor lhc p.rfom.c. of <br />rh. sork aor $hich rhis p.m is hsrc4 My *orkeB onpcn$ri'tr i.s!6rc ceici 8d poliy numb.r dc: <br />PolicyNohber:Jxp <br />I ccnify $ar in rhc r.rrornr coflhewor*forshichrhkp.imi!kisucd,Ishlllnotcnployan,IEnoninanymntr <br />n, s ro ticcotu slhjcd ro rhc wolts conFnsarioi Lss oa Clli,ohiu. a i aEEc rhrr il l .lx,uld h..o@ subj*' ro <br />'rEwodss' or{,cnsalion FDvisions 6t Sccrio. 1700 oI rh€ hhor Codc. I \hiu. ronhuirh 6oply wirh lh)* povisions.. <br />WARNING: Flilurc ro suc v6rk s con .nsalio. orcogc il unlrwtul. and sh.ll subi*r a. .mplofr b cihitul pcdllies dd <br />civil focs !p ro om hundrcd 6ou$nd dollas ($100,000). in lddnion ro tlE @ ol cohF.s.lion. damg.s s povid.d for lh. <br />Selio. 1076 oflhc L$or C.<tc. im.rcd lnd armfty i fes <br />D.le: Applle <br />ucExsE[-(llr&tclaB <br />DECI.ABAIIO! <br />I ncrc$yanirruDd$ pcmxyofF iury 'hd <br />l0n lmtr{n udcr |nvkion olCh{'rcr 9lcommcncin! $irh ssli,n 7ux)) orDivisnrn.l <br />ol $c Bnsin.ss Md Ptufcssiorx Codc. drd trryli.rnr i\ in tuil forc u,ld cfiicr. <br />CAN TBICIIONIENDIXC.d(iENI;I <br />Ihrrchyrlliiinundcr p.mlryol tcrjurr. rhd rhcrc nrconntu.rbn lc n,gascrynnrhcnnonrurccofrhcworklorshi.hrhi\r,cnnitir <br />isu. (Scc :l0S?. Civ ( ) <br />AIELICANLDEI:IABtrIION <br />I lmhr- rllirmundcr I'cnrlry oipcrjury onc olrhc lnlL)*itrg dcchrrrions: <br />Dc.mlirn$ Pcnnn$ (rios Norificrrn{ Fldcril R.!uhrrN lTnlc 10, PM6} <br />-l{cquircn <br />Lcrr.r.i NolincJlt{l <br />_l ccniay Inal rnc fcdcEl rcBllarions rsadinB asbcsros rc'mval aE not afrli.ablc lo rhh pmicct <br />I ccnily rhat I hlrc @d rhh applhario..rn nsb rhd 0E rh6w i.for@rio. k.md.l aCB roomply*irhsll Cnya.d Coury <br />ordiercs and Srsrr ti*s Eluins to building .on$Mtio &d h.Ebyauthriz€ r.rr*nraliEs ofrfib Cily trd Cou yloc.rouFn0E <br />ab.!e @ntio*d pbn ny 16, h$ccftn I,Eto$. <br />A.Dlitui or Aem Sisnsrurc: <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 Ranqe <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 />Meter Release -l t <br />FINAL u 1 tq UtMiq <br />Notes, Remarks, Etc t-l