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1986, 09-22 Permit App: 00013226 Water HeaterMECHANICAL PERMIT APPLICATION WORKSHEET PLEASE PRINT ?i 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 Ste,4 GLJGZGIIC_ DATE /v4 Project 11 /32_7_4 Owner's Name � fret - MI _ as/� Project Address (Street Name & Number) 3 4 i City State 1 Subdivision/ Plat Name Assessors Parcel ' /� / d (✓5 ` ES5Applicant Lot Block Plat # il4L...itt.„) 4 Address / )def__)/j... City O l State GJG\__ Zip 99) ef Phone 9�� 4.3 Va— Business Phone Contractor Address City State Zip Phone /{�j, -�,y 1/74 Contact ( License # QA _ 61 -�o'-iV'G Business Phone Describe Work `;7 i4d b Fans Evaporative Cooler Hoods Electric Furnace/Ducts Miscellaneous • Dryer Range Gas Log Gas Water Solid Fuel/Wood Stove Air Handling Units 0-10,000CFM 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 30-50HP 50+HP Gas Piping 1-5 Outlets ` 6+ Outlets Gas Fired Heating System 1-100,000BTU 10,,,C.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 Ste,4 GLJGZGIIC_ DATE /v4