|
MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS O\YNER AtIII,DT:R DTJI-CARATIoN
<br />I hcrchy rllrn uMrr Fnnlry (n Erjury rhat I Dn cxctrfl ln,n: rhc Cotrkd.ktri Licctr* ln$ nn lhc lbllo$iry rcnqr ls( ?l).ll 5
<br />l]!\inc$ aRl Pofc\\nr CqL): Any Ciry or Counly tr[i.h rcquir$ ! pcn.il lo ('n(turr- llicr. inlpn c. dc x]|,\h or rcnar $y
<br />{r!.rurc. l]rior r. (\ is{r n... ih. rqurcs rh. {tlicrnr i,tr (u.lr Fflnil b iL r siSncd srrcnrtrr rhd lrcor sh. is licctrscd Dursurtl
<br />h rhr liovhi.n\ oirhc Conrtu.tn \ l-iccnrd ljs lchrptcr r. Co ncncing $irh Secrnn,70(x) of Dilili(,n.r orrh.8u!n.\ rnd I
<br />I'tufc$ion\ Cd.tc)orrhrr h.or\hc iscrc rfl rhfi.liotrriiil rhc br\i\ Lrrhc rllcgcd cxcnrui(nr. Any\iolnriotrolSecrion?o3l 5h]rtry
<br />u|],,1i(trllnrrpcanil\ulrccr(lhcinrlicanlIoacivill]cnrhyolnornucrholivchunrcddoll(\(35{x))
<br />-1,
<br />as owM of lh. pDFny. or my cnplorr.s with wdg.s 6 $cir sL @rpc.sarion. wiu rlo rlf woi( ! llE sl turisnor
<br />inlcfld.t or ofrcEn lor qh (Se.7O44. Busincs od Pmacssions Codc: Tne Cm'lEcIor's Lic.trs L!* docs ml q,ply lo & oq( df
<br />thc pbp.ny whot ill! o irpbw.lhcrtr ard *ho des sklt eoii hireltor h.elto. rhmuSh hi d hcr owr cnployccs,
<br />providcd rhar su.I imprewtunlr d mr ill|.dkd 6. oficrd ror slc. lt hoEq, rlr hiuine m irprnwEfl i. $!d whhin om )E
<br />of smpLlbn. thc Owmr Aui6n will lEw llE bu,n n of poving lhd lE or s'E dn ml hild or in{mE dE FotEry for llt lorFE of
<br />-1.
<br />&s owncr or lhc pm,Enr. r'n €rclusiv€ly conlr&.linB f,ilh lianscd conteror ro mn(tud llE rmiccr (S(. ?GE. Au\in6s
<br />"nd PDlnrirn Codc: Thc Conhacrn\ Li..nsc Lrw doc\ nor applyro tr. own.r oaproFdy who builds or improves Ihcrcon.
<br />ond who ontuls aor such pojc.k *ifi a Conindo(n lilcos.d pu6Mr to lh. G retoli Lic{ns Law)
<br />, er crcrur undr SBrion . B. & P.C for'hE len
<br />WON(ETS' COMPIIISATION
<br />DECIAEAIIIIN
<br />I hcEby llfirm undcr pcElty of Fdjury o* of thc folhwinS ddqolionr:
<br />-l
<br />h.ve an will minllin . C.rift.t of Conmr to Sclf.lnsor. for soteB @mD.Bari6r. a prcai(fi fo. by Sm&n 1700 ol the
<br />kbor Cod.. for rhc pfiforn1fu of rh. w* for ehich rh. p.mir is iss!.d
<br />I hnv.rnd will mrinrain workma compcnsdnr in{u.rtr.c. ds rqxircd by S.ctim l?m ollhc ttrbor Codc.lor thc pcrtor{ncc ol
<br />rhc wor* lor whichrhisf.rnrir is Mywo.k c s rtcnsarion insnranft cmicr. I[li.y numbcr ac:
<br />L,o-t-t*
<br />-l
<br />ccnifylhul in rhc pc.fonrotre ol lhc worl for whichlhis Firnn h hsucd,I sholl nor cmjrlo, ao, pc6on in lny tunmr
<br />$ rs t, l,doft suhjccr ro rhc eorler conpcneri.n lass of C!li(,ni!, aid sg@ rhxr ir I shruld trcom subjct h rlE
<br />wortc^ conEnsation lrovisions ofScclion 3700 otlhc ljtor Cdq ! shall. tonhwirhonDly wirh rh.* Fmvhions..
<br />ull.llliul:aNrn crca
<br />DIICLAAAITQN
<br />I hcruty rinruntlcr Nnnlryol ri.ljury rhur I ! li.cn$dudcrpn)!i\i,,ooaCtuprdr91...rnri.ingwirhsc.rion7ux,ofDivi\ionl
<br />oI rhc Bu\ircss8trd Pnrb$hns o)dc. lnd nry liccn$ is ir lnll loie andcfccr.
<br />(s--->"17555e
<br />,".,-.2:}J:1! conl-.,o'J.
<br />coNuf,lJguoN.L[NDEclcrNl]l
<br />I h.Ehy afiirn undcr FMxy or F jury lh.t lhft L\ ! con$dclio! Lndan8 ag.my for fi. Feformmc of lhc worl for *hi.h lhic taoi it
<br />nsucd ( 56. 1097. Ci!. C ).
<br />att,.lclNfuErl./t8tlr{Jl!
<br />I lt[byiillmund.rlcn nyol Frjuryotrcoarhc r.llowin! dc.LrdDns:
<br />DcnDlnion Pcrntirs Asbcsros Nori6c ion Fcdc.rl Rc8uhrionslTnlc.lr). Pan6)
<br />Rrquircdt ($orNorifi.rrion
<br />I .dify thit rhc t d.ral rcguLlions rcgard,ng !\b.{or rcmvdl m not aplli.rbk lo tht prujct
<br />-l.cnify
<br />thlt I hav. rcld rhis lptliurion a.d srarc rhd thc sh,vc info,mrn,n n coft.r. I lgB ro conrly wilh ou Cny and Counrt
<br />odin0nccs md Slarc l,us EhrinS ro huildinS consrruclion.ivcs oarhn Ciryand C.lnrt l.r cnr9 uB{ rlE
<br />nbovc m ioncd po!.ny for insl'ccrion
<br />Arplicatr or Ag.nt Sitnaru6:,?-3t-t a
<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 Range
<br />Other
<br />Hood
<br />Type I Hood
<br />Type ll Hood
<br />Grease Duct
<br />Fire Damper
<br />Openinqs
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.
<br />Final Test
<br />Meter Release I I
<br />FINAL e tltt)t(ZtYl&b l/lz-"
<br />Notes, Remarks, Etc.I
<br />->
<br />\!ARNIN(;: F ilurc k, scurc wo .ri comr.nsnrion .ovctug. i\ unlawlnl and shdl rubJe.r r cnlloycr ro oinnfil I'cdlic! n
<br />.ivil findl!t h onc hundrcd rhou\lnd dolle\ (ilo).mo), ii rddirnnt ro rho co{ ol .onlll.nrdri(rr, drnqcs !s providcd f{tr rh!
<br />SArnlr ru-h r ric Lh1C,{,. 'nr.ft\r r dLrr(+v'\hr.
<br />^,",a4trX ^pp,i*,:x )rt> >TG.A<-r>
<br />C-ezen9*orl
<br />I
<br />tt
|