1987, 10-20 Permit App: 87003553 Water Heaterf
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT 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 provisio s of any state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR
APPLICATION
DATE A') -4%)
Protect# '7-2;i3 4-0
/ -/ �l
Owner's Name Last first MI
5,—,77rte el PIC f. -1 -
Project Address (Street Name & Number ��j
5. 7/ 0 / >,' ; �.)-_s - .?(.;._"2%%,
City r^State
��i�R'C
.74
w'4.
Subdivl
ion/ Plat Name
1-1ILL Yl u 1 -1 �G'I
Assessors reel # .1 4,4 ,rf ` I 1
V l
Lot I
Block
I
Plat it
Applicant
Address
City
State
Zip
Phone
Business Phone
y p/
i q yrl0 Pt
;'rG' '
Address
CliContractor
LI: i?lam • ��
City _/� //
State ,(
Zip
Phone __
Contac / /
(i -"-r, L75ln•,nJ�
License#
JOlid✓'o» /14'614)
Business Phone
: r
Describe Work
vV�
Fans
Ev porahve Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water t .
Solid Fuel/Wood Stove
Air Handling Units
0-10,000 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over1750M
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.,:.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 provisio s of any state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR
APPLICATION
DATE A') -4%)