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MECHANICAL.INSPECTOR RECORD <br />APPROVALS ID/SIG.COMMENTS OWNER BUILDER DELCAXATION <br />I tuEby .ffrm unrhr FMlly of pcriury ll[l t m .r.npl tom rh. Co.rracro LtcNc kw lollnc folld?Fl rce$n (5(7011.5 <br />Bosimss rrn Proltsion Codc): Any Cily or Counry which Eqlircs a Fnn h constdcl, 3116. in{'nvc. &mllrh or qDt ey <br />strucre, Fio! ro irs issrancc. ds rlliEs rh. q'pli.ant for $.h lcmn h filc a silxrd $dr.ftfl rhlr lE or sh. is lt r*d puEu.ir <br />to rhc povthns olrhe Corr6tols Lkcnsd Law (Chlprer 9, CommminB vith Sc.rion ?000 of Dilision I of rh. B8incas and <br />Pmfcxt,ns Cod.) orrhlr hc oslE i! ex.mpt ltErcaom anrl E lE{i. for rhc aucCcd cxcrlprion. Aoyviolrlionofscclion?011.5byony <br />lpplica ior a p.oir subj.rh thc r,'plic&r ro a.ivilpendryofior mErhu nvc hndrcd doues ($500). <br />-1, <br />as owmr of lh. pmtEny, or m, .n{'loyes wilh wrScs .s lrEir $lc $mp.nsrhr. siu &, llE w[ ed orc srtule ir mr <br />inre{H or otrcr.d for slc (Sa.7044, Ausircss ud Pmacssions Codc Thc Conlsrtr x Liccns ljw d.cs nol aptl, |6 !n oenn of <br />lh. pbFny *h) hrildr o, iqrc$ tlE@tr Md sho d.rs slch hr[ hid{.!f o, hc*ell or thrclgh ht o, her ow. emplor!6. <br />lrovidcd rh such impmlc.Enls m ml inlc Ldoronmdro.sh.IlhoecE the hoihin8 o. inpmwE issh*ilhinmrrs <br />of.oq,lclhn. lh. ot"rcr Builrcr wil hrw llE buntn or pmvinS thd tr or sh. dd ml h{ild or irtmw lh. pmFny lor llr puqns of <br />-1, <br />N owrcr of lhe Imp.ny. sm orctusivcly conlrsr in8 wnfi fien*d c.nlmloN lo conslrucl llE l,mj..l (Sc.. 7044, Bur4* <br />,,ld h.f:rsi{ Codc: Thc Cdnro.roda Lk.nsc Llw dci nor {'rly ro d owr6 of nropeny *ho buil& o. innbvcs rh.ao.. <br />und who conlE ls for suh pmjccrs qitn ! Conrfl.to(9 [c.Md punuanr b th. Conhclols Llrtr{ Liw). <br />I mcx.md u.d6 Setron , B. & P.C. for Lhs r{sn. <br />]la.f,4!&:laMfErtAraN <br />IIEIIAXAIION <br />I hcrchy aflnn undcr I'cMlty of !sju', onc ol rhc followinS dalarutions: <br />-l <br />hrrc ut *ill miniain t C.nili.arc oacoMnr ro SrlfiBurc fo. work * comFnstion. G prcvidcd for by Sc.tbn 1700 of rhc <br />ltb., Codc. for rh. petotu otrh. wort for whkh rhc,,cmi b isru.d. <br />I harc and will nBinhin *orkcrl coqxnsarion insuram.. as ftqun d by Scclion 3?OJ of lhe t bor Code. lb, thc l,crfortuec of <br />$c *ori f.r ohich fii! r.rn ir iqsx.d. My workcr' comp.nsarion insurdncc cmhr and plicy numbcr ml <br />-l <br />ccnilyfill ir thc pcrfoi,u.cc oftlrc *ork for {hich thh pcntril is isslcd.l shull mr crnploy lny IcNrn in,ny mnmr <br />$ d( ro l*cdm subjcr rb <br />'hc <br />wo&6* co.{rn$io.laB ofcalilbrni!. and rSrc hot af l *hould h..om subjd lo <br />'tE*ork.r! compcnq ion Imviskrnc ol S*ti.n :l7m of rhc t!h.r Codc.l rhsll.Ionhwnh smpl, wirh lh.s provisioos.. <br />WARNINC: Fdlurc to scure wortcF comp€nsalnrn colcmsc k unh*f!l- and shdl subicr an.mplortr tu dimlbtl p.Mllirs ,nd <br />civil 6ncs o! ro orc hlndrcn rhou$nd dolLrs (S1m.000). in rlrc ro\r .f comp.n\arion. danrscs.s ptuv cd li,r'hc <br />:'wrcny" <br />uicl,nSauQti <br />ol rlt llu\irc\rftl It lr\si,!r\(iidr. rnlnr,- li.cn\c n i',lill lq.crrklcll..r <br />- <br />co r.clor: <br />i\{ulis.. 10i)7 ( ir c I <br />AITIICANLDECLAAA.IION <br />llanbvarlinnunJcr|Itrrlryolpcrjtrryoicof rlrft'lk,8i't!dc.h iion\ <br />Dcnn)liridr Pcnnirs \h({os Norilic[idr l.cdc.rl Rc8uldi({r (litlc J0, Prn6) <br />-lcquncd <br />Lcrler oiNorin.ari0n <br />-l <br />ccnilyrhal rhc fcdsol r.Bulathns rcEddiaB asbestos rcmrol arc not ryplicohlc ro tht DDjcr <br />-l <br />ctnify lhor I harc Md lhir uppli.arion ,tn {ar. rha' th. drv. info(Etion is colRt. I n8e lo comtly wnh rI City a.d Colnly <br />ot rhir Ciry r.d Couly lo ..tft <br />{,"-/3/1 <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 />Rouqh Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <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 />Meler Release <br />FINAL 4?3hr >\?5x <br />Notes, Remarks, Etc. <br />DATE <br />Grease Duct <br />lnstallation <br />Drle: Omcr <br />L iJ '\ N,.rtr <br />Lc!&r'r AddBr <br />- <br />I <br />I <br />tt