|
MECHANICAL.INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS oWNEI' BUIT-DER DIT-CARATION
<br />I hcEby rlliln undcr p.nilry of pcrjury rhd I an cx.n{'r nom rhc a)nr ros'Li.cDsc ljw for rhc rbllowing rnsotr (Ssr0ll.5
<br />DusiN$ lnd Pdcssion Codc): Afly Ciry or CouNy trhi.h ruqunc( r p.nnil n, .onsrBcl, ahcr. i provc. &'noli\h or rcptrt ;ry
<br />ntu lurc. p or h ns isuana. ulqr (iutcs Ihc olplicmr rbr su.h pcrlnil h filc r si8rcd n cmnl thlt hcor shc is liccn{d puEuanl
<br />tu rh. [ori\ion\ ol rh C.nh.kr\ I-i..nrd tjw (Clulr.r 9. GnMrmi.B $irh Sc.rtrrt ?0(n of Divtion I oflhc aunocsa rnd
<br />PoLsions co,tc ) or rhd h. or \h. is crcnD h.e'6nr and rh. tllsn {(tr rhc ,lL8cd cxcnprion. A y tn)ln' ion ol Sslion ?03 1 .5 bt 0ny
<br />rn!licrnr lor ! li.nir su$jcctslhc rlpli.0nl ro acivlltctrolrtoln.r nrrcrhr nvc hutrdrcrldollitr (S5fi)).
<br />-1,
<br />as owner of lhc Fopcny. or !r, en{,lords wnh w!8cs 8 rh.i sh co6pcn$li.n. will d. llE wor* !d llE slnxl@ is nol
<br />intcd.d oroficEd for ek (Se.r0{4, Busircs and ProfcssioN Cod.: Tn Contr.croas Liccns Lsv do€s mr alply ro dovffi6f
<br />!h. ImIErly wts tdlds or ii{mK rh.M[ atd Bh. dcr.Eh rDrk hilmll or hcrslf or lhmuAh his or het o*n cmplorccs,
<br />prcvid.d rhar skh if,pm\tdnts@rcri orded or6,T.cd for s]..lf. howcq. r,r h)ildtr'g or hp@wcn{ L sld wilhii om )t{
<br />olomphlbn, lh Ower Build.r will hlw tlE hun o of |'Dvine rh,l t! or rlrc dil ml hoild or iqmw fi. pmFly for tlrc poqft of
<br />l. es owmr of rhe pop.(y. e rxclurivcly conrlcrinB wnh lietrsed conr6croB ro dlodru(1 'lr ptujcLl (s6. 7(x.t Brsir.*
<br />ad Piofcsion Cod.: Thc ConlGln s Liccnsc tiw dms nol aprly lo !n o*ns of pmpcny *no huilds or improves $crcon.
<br />dnd who onr.d.ri fo. s.h rEjcck*ith. Cooracrn(s) li.cnsd DoN@r t6 rhc Cont&rdls LkIn{ hw),
<br />I n icrcn,fl trn(ftr Sc.rio] .ll & PC lnr rhi\rcrnn,
<br />Drl.:- orM-wonl(rG;aifrmiiiii[
<br />DECI.AXAIIIN
<br />I h.r.by dfm lndd pcdlt, oftBhry om of rlE followirg deldlliom:
<br />-l
<br />hrvrnndwill nni uinrCcniriclrcolconsentk,S.lt:lo\urcn)rworkcrso.pcn\arn,a\phvidcdlnrbysc.riotr.rTlx)orrhr
<br />tantr Cod.,n,(h. Frform,n..orlhc sorl.r whichlh. tEnln is issu.d.
<br />_l hsvcand*ill nEintain *orlcn' .loFostrrioo i.su,arcc-ss Equircn by Sdt n lTm.a rhc Libor q,r.. hr lhc p.rformmc of
<br />lh. wor* ror whkh $ir p.mit is h$ed. My *6rkds .\mpctrsrnrn inslorx Mi.r ffd lrliy numtEr dc:
<br />t8
<br />-l
<br />ccnifytur in rhc tx.formrcc of rhc work for rhi.h rhis pdmir ir issucd, I shlll nol cnploy any Fnon in;ny numr
<br />so N ro bcconr slhJcd ro rhc workd( oq,€nBrn,i h*s of &lilomia. und acB rhar if I .h.nld bccom .ubjer ro
<br />'h.woikc^ c.rrcn\srn,n phlisionr.fScdio.]TOOolrhc rjboi Gxlc.l xhnll. ftnhwirh..nlFly *irh thos psvirions..
<br />WARNING: hilurc ro w!rc wo cr'conEnsion covcrug. is utrl.wtu,, and shall slhrd e mplotlr h dimitul Fuxkx and
<br />civil fincs up ro om hllndEn rlousad dollos (SILD.0OO). in Mdirion h rlrc cosr ot mmpcnetnrn, d!tugri as polidcd fd rhc:;il+f,rn eppauta-
<br />ll( l\\l l) ( ()\ll{\( lr)l{
<br />r)r(t.\R\llr)\
<br />I hcEtylmrmlndcr peEll, of Friury lhal I am licetrsn und.r pmvnion ofChofls 9{comftncing qih Sc.don 70Oo) ofDivisbn:l
<br />oa lhc Businc$ od PmfcsiorN Code. rd ,ny lic$sc is in tull foEc ond dltd.
<br />0 o
<br />colstkt( IroN LI:N t)tNc ,\(: IiN(:\'
<br />AfILICANLPESAAAIIQN
<br />I lrrhy lnif,n und.r pctr0hy oilcrjuryotrc ollhc lollowinB dNlaralnrns:
<br />l)rnx,lilbn PcrnrnlAsl,e(os N.rilicarion Fcdcml &c8ullr io's Onlc 40. ffi6)
<br />Rcqun.d bncr.l Norinciriotr
<br />l.cniryrhnr rh. fcrlcrul r.galari( * eg0rdinS *h.{os r bvaldrc nor+plicablero rhh tmr.rr
<br />-l$diayrh,rlhalcrldrhisalFliclri.nand(,rcrhnrrhcah.!einfffdbri.ni\c.r(rlaerNr..o,nplywirhallCilyondCouolyodinamcsandSrrr.L'wsrcblinBrobuildir8consrdction.edh.rcby0urhorircrc,'rcscnririvcsollhkCn, d Colnry ro cnrc, lron,L
<br />obvc mntioncd nn'pcny ior ir spccl ion 0ut[lo*s
<br />Afdicanl or A8cnl Si8nollrcx I
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Misc. Equipment
<br />Duct Work
<br />Pre-lnsulation
<br />lnsulalion
<br />Smoke Detectors lnstalled
<br />Rouqh Ductwork
<br />Vents
<br />Toilet Room / Clothes Dryer
<br />Residential Ranqe
<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 />Rouqh Mech.lflggt -,'.lJ4d,,)
<br />Final Test
<br />Meter Release
<br />FINAL tt $1|fl,{i ME D)
<br />Notes, Remarks, Etc Ut
<br />APPROVALS
<br />Other
<br />lo,
<br />t*+nye6--l
<br />Ihcn$y.lltmtrfdcr Nflrlry ol l)ctury thrr rhcrc isrcotrirucri lcMnrg r.cN, lor rhc I'( lormmc ol rh. $or\ io. which rni\ pcrmir i\
<br />iriu.d lsc. 1097, ci!. c I
<br />I { {'\ Nin'.'
<br />t-
<br />I
|