1985, 01-23 Permit App: 00004075 Water Heatert
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MECHANICAL PERMIT APPLICATION WORKSHEET /5G1(:,0
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name Last) c tut SEirst) (M)
(1 . r 6.
re/Li I r 4 (
Department Use Only
Project No.
MI
2 Project Address (Not Mai ing Address) Space Zip
3 City/Corpmunity
State
Subdivision/ lat Name
4 Assessor R cel No.
! C25V / (/6S
Lot
5
Block
/
G C i
16 Con ractor Firm Nam �.
is .b. f t `ly N i6,—
Street Address
r_ / 7/ L? -1-v )/A/v.A
17 Zip [ ,l1 f
City_ /7e' !A !U e
State) A
('
Phone )
18 Con ac( rso�
���"� '1' .i '
License No.
4M0 . ,<- 193 N /
Phone if different than above
8 Owner/Agent (if dif erent than #1 above)
Business Address
g Zip
City
State
Phone
( )
15 Describe Work: /•,, ,(' `�7`�''' �,„� �' [ 'c G %
New ❑ (��— *Addition/Ate1 ratio i Replace/Repair ❑
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
8 VENT: Fan(s):
EvapCooler(s):
Hood s):
Duct(s)1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
Range s):
I
Gas Log(s):
Wood Stove/
Solid Fuel:
,4� �+/^
- 0 5. ��y .A. „X (.) L'(
Gas ater Heater(s): `t'() �i� L
11 UNIT HEATER(S): Wall Mount: Y N
Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1000M:
j
14 1000-1750M:
Other:
Pressure Vessel (cu. t.):
15 COMPRESSOR/HP: Lessthan3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU:
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas; Oil ❑ ; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant ❑ ; 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
OWNER OR
APPLICATION/
DATE ( `�-