1986, 06-02 Permit App: 00011652 Water HeaterMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
AS
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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/72)7 /J APPLICATION �i`
OWNER OR %/-h,0 info/.✓. *ii, DATE / ��>U
Project # // 2
Owner's Name Last First MI
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Project Address (Street Name & Number/
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City
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State (`Jr—
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Subdivision/Plat/R 57 /Chas 2-I`1.0
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Assessors l q 275712-- 3008
Lot
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Add ess
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City /
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Zip
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Phone
927— 97/C)
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Business Phone -
Contractor /
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Atltlress
%• 712/
City
'414 o. )te�
State
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Zip
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Phone
44f{71/fir,
Contact / /�J// /-
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