1984, 12-06 Permit App: 00003703 Water Heater*
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MECHANICAL PERMIT APPLICATION WORKSHEET /.31k'C 4
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name Last (First) (M)
Department Use Only
/ i 044Q
/
Project No.—+
2 Project Address (Not Mailing Address) y r Space 64-7.4-)^� - n �% Zip
_Ad/ Lt-tak.-
iy�ri
l9li':� i�iwsiG�T/� Cx /v J `w
3 City/Community
State
Subdivision/Plat Name
WA/Li k/a/k-- AC 4ivt I;)�
4 Assessor Parcel No.
Lot
Block
y
16 Contractor Firm Name
2A4--- -- (V-I.C2-e.---/\--CL____
Street Address
'----. o, & • f,`7o 7
17 Zip
99Z
City
6 -Aa./-
State
�es
Phone
( )-„rGf
18 Contact Person
License No.
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business
Address
9 Zip
City
State
Phone
( 1
15 Describe Work:
New ❑ Addition/Alteration
❑
Replace/ Repair ❑
10 Applicant Name
/� e Ce} -1/-Y —�— -
Street
Address
/0 / �, /
11 Zip
c192fo
City
g a
StatePhone
G��--
( ) 97_4, 53a---
8 VENT: Fanis):
Evap Cooler(s):
Hood(s):
Duct(s) 1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
1 Range s):
Gas Log(s):
Wood Stove/
Solid Fuel:
/ L/1 -l--
Gas Water Heater(s): //6
II
11 UNITHEATER(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:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. t.):
15 COMPRESSOR/HP: Lessthan3:
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 0 ; Coal 0 ; Wood 0 ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; Heat Pump I=1
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
APPLICATION
DATE