1986, 03-27 Permit App: 00010289 Water Heater i ' ,, L - 3oOi
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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Project* ,
Owner's Name Last Fir t , / MI
Project Address(Street Name&Number) { /
F, /'iGC>9 _'-1--4/.4.37/(0,.
City StateSubdivis�io/n/Plat Name
Vg.-PA- La- 'C 14T5 10 11
Assessors Parcel# 1/ •f
,,. Lot Block Plat#
Applicant _/ _ Address �
71 i.,,4_4_I /_
s1 ��., , /z1 ,09 :),Xee
City 1 State Zip Phone
Business Phone
Contractor '.e* _— Address J
,-- •.? C- . -7:.r' L. . C ' •` >/G''7
City '//J� ,} State / Zip��1 / Phone `.¢JJ} ' J
tet
Contact License# Business Phone
,-e41 . 32() .- a i` i- 3. 72
Describe Work ; " / //
Fans Evaporative Cooler (J Hoods u" Electric Furnace/Ducts Miscellaneous
Dryer Range Gas Log Gas Water Htr. Solid Fuel/Wood Stove
>//, - ' '1, )i7.�
Air Handling Units 0-10,000CFM 10,000+CFM
Refrigeration Systems/ 1-100M 101-500M 501-1,000M
Heat Pumps(BTU)
1,001-1750M Over 1750M
Compressor 0-3HP 3-15HP 15-30HP 30-5OHP 50+HP
1-5 Outlets 6+Outlets
Gas Piping
Gas Fired Heating System 1-100,000BTU 10,,L00+BTU
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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 f APPLICATION _ -
OWNER OR X' /'`.r — I �i �-1.:, a L'�-4/1-' -_ DATE �'`,/