1985, 01-02 Permit App: 00003864 Water Heater1—
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name may./((LLast)/� (First) n (M)
/!v/of Y Ill � 1ti 2mie Ori.
Department Use Only --,...2/',(y
Project No .5
2 Project Address (Not Maibng Address) D Space a/ry Zip
///�
qZS
3 City/Community
State
Subdivision/Plat Name
//ijr ItL Wkir—# /17/n1-2"4-‘
4 Assessor Parcel No.
�1-51I-o6,)
Lot
Block
_
16 Contractor Firm Name
Ufa 6 1 ----
Str t Address
,O.8
A. `l in -2
17 Zip I
19270
City
o tYat
State
AA-
Phone -/--
A7P-//70 .-3z0
18 Contact Person
License�nN0. c/� nPhone
&-o. —CVK- a-224)77---
d di event that above
8 Owner/Agent (if different than 91 above) -
Business Address
9 Zip
City
State
Phone
15 Describe Work:
New 0 Adtlitionl Alteration 0 Replace/Repair `�'
10 Applica t Name
�fG1 .ti ttaa .hL
Street Address '�77/Y��
.SIS 3. I& Ja. xi,'
11 Zip UU
9�1a/L
City
6-/0/9:-/e
State
Cek
Phone
(-x'9' jus -04 —ta/
8 VENT. Fan(s):
Evap Cooler(s)'
Hood(s),
Duct(s) 1'
/
Miscellaneous'
10 APPLIANCE:
Dryer(s)'
1 Range s):
Gas Log(s):
I Wood Stow/62—/A-C,.Solid Fuel
Gas Water Heater(s): 171,000
11 UNIT HEATER(S)' Wall Mount Y N
Floor: Y N
Suspended. Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM'
13 REFRIG SYSTEM BTU' 1-100M:
100-500M'
5110-1000M'
14 1000-1750M:
Other:
Pressure Vessel (cu t.):
15 COMPRESSOR/HP: Less than 3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM' 1-100,000 BTU:
100,001+BTU:
18 TYPE FUEL SOURCE: Electric 0 ; Gas 0 ; Oil ❑ ; Coal 0 ; Wood 0 , Solar 0
19 TYPE DISTRIBUTION: Forced Alr 0 ; Radiant 0 ; Heat Pump❑
1* Number of separate zones for any heating, A/C or air handling system.
I certify that the above information as submitted by me is true and correct and further, agree that all pro-
visions of laws and ordinances governing this type of work, including inspection requirements, will be com-
plied with whether specified herein or not. The granting of a permit does not presume to give authority to
violate or cancel the provisions of any state of local laws regulating construction or the performance of
construction.
SIGNATURE OF , APPLICATION
OWNER OR d/S� S c Y� t,9 Q DATE
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