1984, 10-23 Permit App: 00003094 Water HeaterF
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (L t)(//Fi'r's) / . - (M)
74,3 Yi1-4,.-1v
Department Use Onty p,
Project No.
2 Project Address (Not Mailing Address) Space Zip
E: i /r -O3 6-4.e-- g yzoG-
3 City/Community
State
Subdivisl�at Name C'� �7
4 Assessor Parcel No.
•2.-S544 -071'1
Lo
lei
Block
.7
u
16 Contractor Firm Name
,..-....7e, dA q - Kii-J— -.4`7"
Street Address
- c. 4 . a 76.7
17 Zip
4'lzzo
City
dGatca.
State
'0
Phone ��4
...(. ) 39.1/70 t'
Phone if different than above
18 Contact Person
4 i.52/zL.861-0V -
License No.
3.12 -CL -
- 72A) T
8 Owner/Agent (If different than 01 above)
Business
Address
9 Zip
City
State
Phone
( )
15 Describe Work:
New 0 Addition/Alteration
0
Replace/Repair 0
10 Applicant Name
Fd'i�1-d--��
Street
Address
a ' //?o3 t�a�
11 Zip
1' 976'6
CityState
�./b/Cit.fv _
)
/e /1k,
Phone
( ) :7 - 7c.7
8 VENT: Fan(s)'
Evap Cooler(s):
Hood(s)'
Duct(s) 1.
Miscellaneous:
10 APPLIANCE'
Dryer(s).
Range s):
Gas Log (s):
Wood
Wood Stove/
Fuel.
..
Gas Water Heater(s): /G , )
-Y -1 C
11 UNIT HEATER(S)' Wall Mount' Y N
I Floor Y N
Suspended' Y N
12 AIR HANDLING' 10,000 CFM or less'
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-103M:
100-500M'
500-1000M:
14 1000-1750M'
Other
Pressure Vessel (cu. t.):
15 COMPRESSOR/HP: Less than 3:
3-15:
15-30:
30-50:
50+.
16 GAS PIPINGSYSTEM' Number of outlets'
17 HEATING SYSTEM: 1-100,000 BTU'
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric 0 , Gas '0 ; Oil 0 , Coal 0 ; Wood 0 ; Solar Eln
19 TYPE DISTRIBUTION: Forced Air 0 , Radiant 0 ; Heat Pump
1' Number of separate zones for any heating, A/C or air handling system.
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 // /J /� J /,
OWNER OR `� ( LLL�.(' /L/rl�ce—
APPLICATION /�J//�/Dr
DATE D