1985, 05-15 Permit App: 00005503 Water HeaterMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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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
OWNER OR
F
APPLICATION
/()(71, DATE
Project # C`
Owner's Name Last", First ? MI
LC. � ilti i "9_Z') .Xt-L ' { �2 -
Project Address (Street Name & Num r) (../
City
/f " r, �/ e
State !
Subdivision tatt Name
-1`i / i�
Ass ors Parcel # �, ff (tietie.r
Lot 1
... ,,
Block
Plat #
Applicant
I:4P k G(/C `..1A•7/)
Address
I; • ,// T'-' ' �i .C/G47i.Jc:m.,r
City ' / 4
=--fi A, // -721-/
State
a )6,:-._
Zip
q9/ -;_h;
Phone
Via' e, ' -_ 07 —
J
Business Phone
Contractor:�y1/�% 5 1 p
- (Ca
Add . / 1
City 4 ,,
)----. g.--
State
46-
Zip
q ? l'
Phone 4';_..\(/-
/ f 17�C) -)76.71
Cont i -
License #Business
Phone
Describe Work �/ /�
1�O et.' l ---6 )U }�
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Wate
Htr.
Solid Fuel/Wood Stove
Air Handling Units
0-10,000 CFM
10,000+CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-30H P
30-50H P
50 + HP
Gas Piping
1-5 Outlets
6 + Outlets
Gas Fired Heating System
1-100,000BTU
10v,.:00 + BTU
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
OWNER OR
F
APPLICATION
/()(71, DATE