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MECHANICAL.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUTLDER DEL(ANATON
<br />I hcEby 8ffirm undc! pcnally ofF+ry rh3l I d cr. /iiomrn Co racroF Liccns kw for rhc tollo*ing @s! (S.c,7011.5
<br />Busincs ,nd Prcfesrion Code): Any Cny or Cou.ry *hich r€guiei 3 lonir ro @nslocl. lhci inpro$, rlcmlish or EI'!n ey
<br />shcM. rhr t6 ir. i.su,m.. dso rcquiEs thc srplk. lo, such Fmi ro fiL . siencd sl,l.c.t ihal tf, or sh. Ls lkcnltd luNel
<br />to th€ pmlishns olrlE ConrDcxtr s Liensd Lis (Ch!flcr 9. Cohm*ins sirh Sc.rion 7O0O of Dirision I of $. BusiNs.nd
<br />P,bfesiions C6dc) .r $ar hc or .h. is .rcnp thcEfiom urd rhc b.!h fo. lhc llh8.d .ftrpiio.. Any viol,iioDol Sc.lion 70] L5 by &y
<br />lppli.ant for a Fmil slbjNls lh. apt,licant lo s.it il Fmhy of nol mm rh 6vc hundEd dollss (S5m).
<br />_1. I ow@r ol ihc popeny, o. my enDbyes wnh wrgcs &r rhcn $L! conFnsllion. vill do lrE wdt !d rlE stEtE ir ml
<br />i c,xh or of.rcd for ek (SE.?o&. Busimss !.d Prof.srions Cod.r TIE C,nrftlols LLrn* L{w dcr nol q,!ly h an owftr ot
<br />rhc l,oFny sho !.ildi or in+iDB rlxtutr rld whd dq Mn k.i hinklr or h.elf o. lhm!8h iis tr h.r own .nplorrcs.
<br />p.ovacd thar such itrqmkmnls @ fr'r hlcnd.t or oficr.n fot sk. lf, howwi rha hrilding o, itfiftE h $ti wilhin orc )€r
<br />of oft{,letion, itf, Owr Buildcr wiu h,E llf ttrdd of rmvin8 'h.r
<br />lf, or slrc dil mi hiE or iq,bw rtu [rolEry fo, llE lllrFc ot
<br />l. rs own r of ttu tmtcny, onr cxclrxivclt lonlrn lin8 wilh licctrsd conkflors lo onsrtoct lhc prorNl (Scc 7044. BusiEsr
<br />and EDi.ssionCodc'IhcConrrrctolsLiccnscLawdocsnor.mlrtoaiowneroflorcny*hohuildroriorovcslhcrmn,
<br />and Rh. conrrdls tu s!.h pn*.r$ wiih a Conrd.k d\) liccnscd pxBunr r. $c Codracbrs Li.cn$ tr*).
<br />I an.rcmt xnd.r sccriu
<br />IYoRKFRS' CoIITPFNSATI0N
<br />DECLAf,ANAN
<br />I hcrchy aalrfl lndcr pcMlry olFrjuryonc orrhc Luo*ine dc.lnrarions
<br />I hnvr Mdwill roinrrin r Ccdiilcare ol cun$nrh s.l[Insur lor *o.*c^ .o'n .nsarior, rs troridcd nn hlScdion lT0Oolrhe
<br />tlt$,.'rh. fn' ,hc Frfo,nbn.c nf,h. *o'k f,r trhi h,hc |c,n,i i. ir\Jcd
<br />rZ( ru c ana " r n monm n " ukc6' cornnctrrJr r.tr insurrnlc. as Eqltcd by Sccrin l?O{} of I h. Lrhr Cod.. lnt rh. lElforrok. or
<br />uorkcn conrD.nsdrio. in\lrancc cari.r ud policynuhb.tdc
<br />+Fn
<br />Ll
<br />-l
<br />ccrrify lnar ir rhc D.rfonmtre olthc qorl for which rhh pcrmit is issucd- I shlll.or.mtloy dny IcB.n in 8ny mn.cr
<br />n, Itu l..com.ubtccr ro rh. worrds cont .s ion INwiotcltir.nia dnd.erc.lhal ilI should tEcom subicl lo lhc
<br />worksc conrcns bn ,'r,vhi.ni of Sc.rn,n 1700.l rhc tjhrr Co<lc. l shrl, ronhwirh mmply wilh thor pmvhiotrs..
<br />WARNING: Flilurc ro wurc workcs' conDcnsJrbn covcmgc is unhwhl and sholl slbjer M cnDlorrr lo dininrl p..rlras and
<br />civil nncs up ro om hundEd thous.nd dolles ($ion to rtc cosl ot comnciqtion. damscr d\ Dmvid.d for th.
<br />SRtion 30?6 ollhc tihr Cod.. inl.rcsl lnd !t
<br />LrcE!5ID!!}NISdCIAB
<br />DECI.ABAIION
<br />I h.rcbylffimrundcr pcnlltyolrrjuryrh l om lirna{ undc. rrovistun of Ch,pr$ 9 (.o.rft&inE wnl sdi irtr 7fiD) of Ditition .l
<br />nl rhc susitrcss ond hotc$ionr Codc. ud my liccnsc is in full fore ad ctlccr.
<br />N
<br />Cl,tlliIBjIrIIONInlUNGTIIi.El.l:I
<br />I hcruhy rrfiro undcrytrrliyor txrjury rhar rhcrc i\ r cotrnrucrbn kndi'rg,!.h.y Lr rhc ftrr nrun.c olrhc work lb, *hich rhn pcrnrir h
<br />ir{cd (s( 11097. ci! c.).
<br />AITLICANfI]ECI,A&IIION
<br />I hr$y allid undcr !.nrlrt orpcrjury onc ofrhc lalk,*inr dcclamrion\:
<br />Dcmolirion PcnnirrA\h.jo\ Norificnri(r l;crl.rilRcAuldri(,n{(_Iitlc 40, Pfi6)
<br />-Rcqutql
<br />l.llcr oI Norifi cari{{
<br />I cdifyrhar rh.fcd.rul r.Erhrionr dgariling r$Gt,srctrx,vdld nor rmlkabh h rh$ pmjd.
<br />-l
<br />csrily lhlr I haE rcad thh ion dd srarc rhd tlE utovc inlornErn,n k .(lrer. I ag@ 16 condy wilh al! Cily lnd County
<br />odiMnccs atrd Srarc tiws rlar ion. 0d hcrcby aurtsrirc rcprckntalivcs of rhis Cir y end Counry lo .nro trA,n rh.
<br />ahor mnrioni p6r.ny for 7-7o -
<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 />Rouoh 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 />Rough Mech.
<br />Meter Release
<br />FINAL
<br />Notes, Bemarks, Etc.
<br />Other
<br />Final Test
<br />I
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