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MECHANICAL-INSPECTOR RECORD
<br />APPROVALS DATE tD/stG.COMMENTS OWNER BUILDAR DEI.CARATION
<br />I hcEby lffirh lnder pcMlry or pcrjury rher I M cremfl fmm th. Contmclou Lic.ns Lq for thc followitS rc{$n (Sa?031.5
<br />Busin.ss ond Prcf.sion Codc): An) Cily or Couflry qli.h rcqliEs a psmn ro @nstrcl. .xc. irpmvc. d.mlirh or rcp{t dy
<br />srMrm. Fior b ns Gsu!re. lto EquiB lhc !t plicdor fo, ren pcmir lo file s si8*d shlem lhal h. or shc ic liccmcd purs,nl
<br />$ rhc provhions ol E Conrmtoas Liaflsd ti* (Chtrpler 9. Comrctuing {irh Sc.lion 70{0 of Oivhhn 3 of llE Blrin4i and
<br />Pre|'sions Code) o. rhlr lE or 3la i cxcmpl llEeloi ard llE hssis tor lhc alhgcn .xcnprion. AnyviobtonofScdionT0ll.5byany
<br />aopli.,rr for s p.rnir 3ubj(ls lh€ appli.anr fi, acivillcnalryoanor morc fian nvc hundrcd doU.tr ($500).
<br />L ar o*Ni or rh. pnFny. or ny.ntloyR. wilh *a8s $ lhcn $b om!.nroliotr wi[ do tlE work &d E srrrtt@ k ml
<br />inrcdcn or oilcrd for sdc 1Se.7044, Busimsi and PNlesib.s Codcr Th. Conlmttr s Liccns Llv docr nd .nply ro e ow*r of
<br />rh.pmpcny wth buik s d ir{mstlEatr &d who dErsuch w hims.lf or hceltor thmugh his o hcr own.mrloyccs.
<br />lmvid.n rhri rr.h irpovmnis ac mt i.tdrhd m otrcr.d for slc ll hopcwr thc hoihirg or iq,mwEil h sU *irhir .E
<br />'dof@nFlcrir,l! lh€ Ow6 Bui&r vill hrw itE hn&n of pmving dd lE or slE dil ml toild or iryftt lhc pn,rdy rd Itr prqDs of
<br />-1,
<br />ns o$ncr of rhc tbpcnr. am cx.lNi vcl, .ontri.l ing silh li.cnEd .ontmdoF lo @nsrocr rh. fei*r (Sc..7()44. Busrncss
<br />ad Eofs{on Codcr Ttc Conrrlcroir Liccns. Lrw d@\ n.r stpry r. anowns ofrrotcny qho builds or improica rhd.on.
<br />and vho .uorBch nn $ch pruFk wih ! Conrmdon9 licensd llursunt ro rhc Co.rra.ror'r Lecn\e bs).
<br />-l
<br />m ercnpr otrdcr Serio
<br />EOBf,EXI].CI}MIENSAII9N
<br />DECI.AEAIIQ!
<br />I lFrcby rlrrm undcr p.noh! of pdiury ore 61lhc folh{h! &rlanrionsl
<br />lhdrcd sillnui ri.nCenifi.rlcolc.nscnlr,Sclllnsurct,Nork.h(or1Pctr\dnnr.a!lmYidcdlb.hyS.crn,n:1701)urrlrc
<br />bln Codc,,(tr(hc pcrrornrn.c.llhc qork ntrqhich rhc Dc!nrir t is{cd
<br />I h,!c 0nd {ill moinriin s.rtcn conBn\arn in\!rd.c, n\ tuqrncd h! s(r ion .l?(r0 nr I hc Libor Code. ad (hc p.rrorron c of
<br />rhc Noll for*hichlhn ncmir i\ t*d My sorrc6 .onncnern,n in\xhn c cntrtr {nd Ix lt) numb.r dc
<br />Ycnrr,'hd mrhcFll mmcoflhcwn ntr *hichrhispsfrn isL$ucd.l sh,llnorcnPlo,anyPcBoninaoynlnn.r
<br />$ sro r(om {hjccr ro rhc s*r'omn n{rrn bwr otC.lilom6, and reEc thd irl sl,,uH bc6m rubF! rorh.
<br />so*sl mnwnsation pmvirions ot Sccrio, l70O of rh€ Lihq Codc I shall. fonhwilh €on{ y wilh thos lrovirions.
<br />WARNINC Failure ro $cm *orkcd s'npcns ion mvcnsc is unlowlul, d shlU rubjccr M cnl'hre. ro nin nal lEmltix a.d
<br />.ivil n..{ u! 16 onc hundrcd lhouslnd dollan ($l iI rdn rii,n r,) rh. .on ol ro rt)c \lii,n. dr lcs ar fnivi(ldJ 1,tr rhc
<br />sc.rion 10?6Dfrhc Lrln Codc, inrcrcsl ond
<br />DECI,ISAUA]I
<br />I h.rchyufilnundcrpcmhrof lury rhnr Ion li.cnrd uMcr l&vi\n,n ol'Ch Plcrr) (ortrr cir18 tith Scdio. T(xtr)oiDlli\ion.l
<br />or rhc BurirE.sUkl I'rc,.ssiuNCodc. u,xl nry llrrn\c i\ n lllltu(c rtrdcflc.r ,,
<br />?o\Ltlt
<br />ot\
<br />laNsll.llllll0N.LliNlllNlrlliliNc}
<br />I hcrchy rlltnrundcr nculry ol pcrjrry rhd rhc'c i\ r con{tu.rirn lciding alc,Ey lir rhc FYnmbncc o{rk wdk lor shich rhi\ Fnnit i\
<br />n\x.d rS.. 1097, Civ C.)
<br />AIILIIANLIE$AAAIIQN
<br />Incrc6y3ninnh er pcnalry or FrJUry onc ofrhc rollowtre dNld.tions:
<br />Du'nolirio. Pcnnirl^sb.{os Noliic ion lcdclol RcAuhtio,s fl]lh 40. Pcn6)
<br />-Rcquncd
<br />brrc, o,'Norilicdi,n
<br />-l
<br />anity rhlr rhc lcd6l EgllrtioB ESd,ning ab.slor Emval !rc nol !0plk8bk lo rhis lJojecr
<br />-l
<br />cenify rhar I havc rcad rhis apDlkarion ard sarc rh llr .h.v. informlion is coret. I dse ro .or{ y *irh aU Cily lnd Co!tr|,
<br />odi,D..cs and Sidc tiws rcl,l hcEby aut horizc rq,rcsntat ivcs o a t his C il y a.d Cou yto cnt.r uFn th
<br />.bow mnrn,ncd pmFcny l'or
<br />A!'pli.anr or ABcnr si8nato v<E tu",.-7/a/4<l
<br />Appliances
<br />Metal Fire Place
<br />Evaporative Cooler
<br />Furnace
<br />Compressor
<br />It/isc. Equipment
<br />Duct Work
<br />lnsulation
<br />Smoke Detectors lnstalled
<br />Rough Ductwork
<br />Vents A
<br />Toilet Room / Clothes Dryer 2-70-tY x\u)0)
<br />Residential Ranoe
<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 />Rouqh Mech.
<br />Final Test
<br />Meter Release
<br />FINAL r-9 -lr x,w1t)
<br />Notes, Remarks, Etc.
<br />Pre-lnsulation
<br />(Qrr-( t l',e I
<br />T
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