1986, 07-21 Permit App: 00012193 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 APPLICATION
OWNER OR DATE
Project #
Owner's Name Last First MI
VE ON G 5�rc-,oM6-
Project Address (Street Name & Number)
C
City/�1i
\S e) � ,q c
State
(,(' /A S N / ry 6 �`d N
Subdivision/ Plat Name
l35V csP L14i LLS /57 -
5TAssessors
Assessors Parcel#C — O
Lot
Block
S
Plat #
Applicant
Address
City
State Zip
Phone
Business Phone
Contractor
S �'a K �9 NE El�G�2 r c. Q
Address ,
/y.a� �V #A MI
City_ Q N
State Zip9,.7
Phone D 'Y' — L16 C/
Contact
License #
2po f, c 1-1 i 6 SZ_
Business Phone
/,/,r�z -
Describe Work
Fans
Evaporative Cooler
Hoods
Electric Furnace/ Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
41D'0, -y3 �J)
Solid Fuel/Wood Stove
Air Handling Units
0-10,000 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1 000—M
1,001-1750M
Over 1750M
Compressor
77P3-15HP
15-30HP
30 -SOH 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 APPLICATION
OWNER OR DATE