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1986, 11-14 Permit App: 00014236 Water Heateri %f r` MECHANICAL PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAN ►20 )too I certify that the above information as submitted by me is true and correct and further, agree that II pro- visions of laws and ordinances governing this type of work, including inspection requirements, will b com- plied with whether specified herein or not. The granting of a permit does not presume to give auth rity to violate or cancel the provisions of any state of local laws regulating construction or the perform-nce of construction. SIGNATURE OF OWNER OR APPLICATION 7/ DATE 1/4 Project /.4/286 First ' MI Owner's Name Last (F ! / A Project Address (Street Name A Number) 1) 6,„2.3 .F .\12te-c--> City 4l k. State /06-- Subdivision/ Plat Name Adt RAeEAci 'value/ Assessor Parcel N005I/ I — 651 3 ! J Lot , 3 Block -5 Plat k Applicant �t/d .Lc eE Add ess ®� /l 3 F.-.i`zewe---) City �a�� StateZ612-4 /,v/� G/ Phone *-z - OS/ _5 S7 / Business Phone f�5_ 5777 77 ,J Contractor Address City a --- /r. 1P—, State /.0G._ Zip f°' q24� Phone� G �9// Con . t _- PI& / f /Mr c2.-) License a j_V -41-5f ,57an/% Business Phone Describe Work �,��/�f�////) W,, `1 Fans Evaporative Cooler ( Hoods Electric Furnace/Ducts Miscellaneous Dryer Range Gas Log Gas WaterH, tr. `�/`�1000 Solid Fuel/Wood Stove Air Handling Units 0-10,000 CFM 0,00+, 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 1-100,00OBTU 10,,,x00+BTU I certify that the above information as submitted by me is true and correct and further, agree that II pro- visions of laws and ordinances governing this type of work, including inspection requirements, will b com- plied with whether specified herein or not. The granting of a permit does not presume to give auth rity to violate or cancel the provisions of any state of local laws regulating construction or the perform-nce of construction. SIGNATURE OF OWNER OR APPLICATION 7/ DATE 1/4