1987, 01-12 Permit App: 87000108 Water Heaterin
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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Project # /0-€3Owner's
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Name 6d -4;N -et 'V) Last First, M
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Project Address (Street Name & Number
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SubdivlajeglP Name
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Assessors Parcel # 2-gSik —. ik,, ! # '�
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Lot
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Plat #
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City
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State"
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Zip
99 ars 7
Phone
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Business Phone
Contractor
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Address
City
State Zip
Phone
Contact
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License # egF 2i[gi
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Business Phone
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Describe Work
Fans /
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Wate Htr.
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Solid Fuel/Wood Stove
Alr 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
15-30HP
30-5OHP
50+HP
Gas Piping
1.5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10v0:00+ 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 , �a _ 177OWNER OR DATE