1986, 09-05 Permit App: 00013153 Water HeaterMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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��. /L,--7/2—
Kms//& APPLICATION �d�
OWNER OR I DATE � `} �
Project #
Owner's Name Last First MI
Project Address (Street Name & Number
\ S' 3.3O?b en/(4141c /?D 4 0
Cityfile--Stets
4/7 ir G
\A��
`A p�
Llf�/JW
Subdivision/ Plat Name
Assessors Parcel #
Lot
Block
Plat It
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor
Oo4�r v4_,/e___c.
2C V4.�5-0-57
Addr
r &,VT
City
Sn. I�-----
State
thA
Zip
79a) Z
Phone
357 47971 --
975
Contact,
ContactLicense
.9 X10
M
WV Ya4 - /7v,fz---51/434/-
,t24w
Business Phone
K9Y
Describe Work � ^
J) s7.¢ 1/ 6°'m ‘,0-4- -re-4 jCJir<(-� /P % O C IS°7 / r' Vr-S
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Wate Htr.
Solid Fuel/Wood Stove
AV Handling Units
0.10,000 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over1750M
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
1Q,,,;00+BTU
\5, • 00
-C cD
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��. /L,--7/2—
Kms//& APPLICATION �d�
OWNER OR I DATE � `} �