|
MECHANICAL.INSPECTOR RECORD
<br />APPROVALS DATE tD/stG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcEby dfirm !nd( Fnrlry of perjury thd I am cx.nfl lmnr rh. C.dmroN Liccne Lrw for lhc folk*ing easn (Ss.7011,5
<br />Busi..s !.d Prolcssion tuc): Any Cil, or Counly *hkh r.quircs r Fflil lo onntud. !lld. in{,mvc. .hmldh or EFtu sy
<br />srructure. rtu lo irs issusKc, !l$ r.qriEs rlE applicair tor such l,crdir ro lilc a sigftd (0rcrc lhli ft or snc is liensd l,lNanl
<br />ro rhc lrvhioB of dE Co.kaclols Lisnscn t,v (Chsr,l.r 9. Comncins wilh Secrion 70OO of Divhion 3 oalnc Busin s md
<br />Pmf.ssions Codc) or rh ncor shc n cicnllr rhcrcfiomlnd thc bash for th. alhScd cx.mrrion. Anyviol ionofsdi.n?011.5hyany
<br />apllicant for a pcmir subj(ls rh€ lpplicanl loadvilpcnlhyofflor mrcrhan livc hlndrcd dolldi (t500).
<br />_1. ,\ .wnc, of rhc poFny. or my .nplor!$ wirh wa8cs es
<br />'hcn
<br />sb !om!,cns0rion. (ill do lh. wk aid rh. slBt$ ( ml
<br />inlcnd.d tr o6.rcd for $L (SN.?044. Busirc$ lnd Profcssions Cod., TrE C.ntu loas Liccne kw das rcr lpply ro in owmt or
<br />rh. top.ny who builds or im0mvci rh.mn. lod *ho das sh kd hins.lr or h,slf or rimuSh his or hcr osn cn!loy..s.
<br />p.ovidcd rhor srch an{eEmnls m ml hl.nd.n or oficEd ror elc. li trwi th. ldiuing or iryrowEnl i5 old ehhin n( r-
<br />olonphriotr rlE OwM Bui6, vill taE Inc tI.d.n of Imving thar lE m {E dA hr tuiU or iqftE 0E lrqrny for ltE purFt$ oa
<br />-1.
<br />os owncr oflhc polcny. amcichsivclrconrradin! wnh liccn{i conlEcrosro 6niBd 'lr lmid (SB. ?044.8u\inst
<br />.rn ADft$hn Codcr Thc Conra.rors Liccns.l-uw docs.or rpplr ro tr. o*ncr ofrropcny who b!ilds oi impnvcs lhcrmn.
<br />md who snrBcls for such pmjers $irl' s Co Ero(9licc scd rtuGNr rorhcConncrofr Li*.s lxw).
<br />I mcrcm.r undcr Sccriotr ,B,&P.C forrhi(rc@.
<br />Ownc.
<br />uoaKEEli:c!)MfrNsAIoN
<br />PEII,ABAIIIA
<br />I h.rchy afirn lndcqEn.hy of pcrFry orc of lhc folloqiry dslEllio.s:
<br />lhlcx ,l \illntri'trr rCcnin.rlcofCrf{ctrr h Sclfln\urc n'r sorkcra corn!n\xri,n,. i\ Ix,v'dcd tr hySccllot l7(x)ol lhc
<br />lihr Cdlc. ir rhc I('li)nuncc olrhc (ork nr !hich rhc pci,nir N n\urd
<br />)<fhak onJ uirrtu(hh eod.cB'.or rhc Mrk rorwhkhlht n nn k nsucd
<br />mp.nsalion irsummr, as Eqlircd hy Scction 3?00 of rllc khor Cod., for rh. pcrlonMrcc of
<br />My wort rs mn{*ns{ln,. insur!rcc csEar ai.! Iloli, tunbd ec
<br />@
<br />I ccniryrh,r in rrcrlonmkrofln u'ork ,br qhth rhis pcirnn is i$ucd. I shrll nor .nploy ,ny ,.Nn in tny nmomt
<br />so sk' hcom subjccr ro thc wortcF q,q,cngrt,n lrws ofcalifofrir. and almc rhd ir! snould tEcom subjd lo rhc
<br />workql ompcnsrlion pn,risidn\ ors..rion lTmorih.lrtrr Codc.l sh,ll. fonhsnhcomply wilh rnos pmlhi.ns
<br />WARNINC: tbilurc lo wlrc *o*cr' onFnqlion ovcmsc is lnlawtul, Md shall sublrl e cmpk,ys ro aiminrl F,ulrii and
<br />.ivil fincs u! Io ore hrndrcd lhore.d douus (3,00,000). in addirio. ro rh. cosl of comp.nkrion. danuges 3s providcd fo,lh-
<br />LlcExsrDroNl&\(:Iaa
<br />DECI.ASAIIAN
<br />I hcrcb,alfirnlndcrpcnaltyorFrjxryrhd I n hccn\L\i lido pn,vi\n or Chrpld 9 (co,nmrc in8 sirh scdi('i TIxx)) oi Divi\ ion I
<br />ol rhc Busircss r Proicsri.rs Codc- lBl mr li.ci\c h in fllllbrex crNr.
<br />e-zO 262
<br />3
<br />caMiralcroNLrN[INc.rc8 r.r
<br />I hcEhy r,rtnrundcr Fnahyol F-rj$y rhar rh.E is a.onstu.rion kndirp dscn.r lbr lhc F-rlinnrme ollhc sork lnr whth rhi\ Emrir ir
<br />i$ucd(scc 1097. Crv. C ).
<br />l.cnifyrh rhc ltd.idl rc3uhtions rc8 (lnrg !\hcslo! rcnn)vil !rc norapplicablc t, rhn tmJ..t
<br />l..niryrhar I hrv. tad rhi\ trtplicrtioniM {trrc rtu rh.re,vc itrhnmti.n i\corccl l ErL{ 'o
<br />Lrnn ywirhallCirylndCounry
<br />odin!tus dtrd Slarc Llws rlaring 16 building .on{ocriotr a.d lE!.by ruhori4
<br />ubovc mcntiotrcd pnFny rbr inrDcdion
<br />Amli.ad or AE nr Srgirrurc
<br />'"*'*"""'::")ruu*
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />Ivlisc. 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 />Openinos
<br />lnstallation
<br />F.D. Drop Test
<br />Above Hard Lid
<br />Above T-Bar
<br />Rough Mech.
<br />Final Test
<br />Meter Release
<br />FINAL d gl'rln -ilJ b
<br />Notes, Remarks, Etc.
<br />:":2&\tY;#,1 6_
<br />Lcnncr'\ Addrcs
<br />-
<br />,upr rr:,rlrilxii luirtiF
<br />I r.B'by dtnn nnd.r Nn0lr, ofpc,juryorc olrhc tulloBins dNhr.lions
<br />Defldlnnr PcrnririAshc(o\Notillcarion Fedcral Rcsullri,'n\(Tirle40, Pd6l
<br />-RcquiEd
<br />lxrlcr of Norifi .aridi
<br />---+--
<br />=
|