1984, 11-14 Permit App: 00003504 Water Heater*
H
z
W
a
5
W
LL
0
W
a
>H
0
z
cc
W
co
z
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (FALLeityL, (M)
Department Use Only S-0
•
Project No. 2
2 Project Address (Not Mailing Address) Space Zip
• / Czl L> n-2_-. i 62''q7J4;
3 City/Community
State
Subdivision/Plat Name
4 Assessor
14
Parcel
542.--
No.
10®5'
Lot
Block
16 Contractor Firm Name"
Street jAddress
17 Zip
Q/2 -7.1J
City
CL) CZ) -2 e____,
State
l� 2L
Phone
( ) �d 7/76 2c,
Phone if different than above
18 Contact Personj ��
J�/�i
Lic se No.
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work:
New ❑ Addition/Alteration
❑ Replace/Repair
10 Applicant Name
ez,fryts
Street Addres A �) A `'
C-- / (7
11 Zip
City ,/!
State
Phon
8 VENT: Fan(s):
Evap Cooler(s):
Hood s):
Duct(s) 1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
1 Range s):
Gas Log(s):
Wood Stove/
Solid Fuel:
Gas Water Heater(s): 4.5
11 UNIT HEATER(S): Wall Mount: Y N
Floor: ) 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:
500-1000M:
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:
//d/ El TYPE FUEL SOURCE: Electric E ; Gas r • Oil ; Coal ❑ ; Wood ❑ ; Solar
`
19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant ❑ ; 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
OWNER OR
6„)/a2i2
APPLICATION /7
DATE �