1986, 08-18 Permit App: 00012681 Water HeaterMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THEFORM 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 provisions of any state of local laws regulating construction or the performance of
construction.
OWNER oA°`�G/Q� ,
SIGNATURE OF f APPLICATION
OWNER OR � .Ce' / DATE / $ k
Project # (`Q V /
Owner's Name Last First MI
Bcgt1F 5 • E/7/ /
Project Address (Street Name & Number)
E /3 o 5/9L/ SL j ci
City/
S' aiF AB
State
142 'a
Su ion/Plat Name
R
rtrulTr 1( ‘3R0Assass
Parcel#+ _541
?4'[7 r 2LAI
Lot Block
3
Plat #
Applicantt /
// e0 a
t6I/,/ �/` ici_
Address � / r
£ /3 /r// fi7A7 S/ ,1
City
State
X4
Zip
?7,2/ e
Phone
91.2(-577 Y
y0A/9N/
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
r
LtoerreeP11
Business Phone
Describe Work 1 '
"72./..ez•-- .e...31,zeo,..
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr._
/110`,,0000+
Solid Fuel/Wood Stove
Air Handling Units
0-10,000 CFM
CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
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 provisions of any state of local laws regulating construction or the performance of
construction.
OWNER oA°`�G/Q� ,
SIGNATURE OF f APPLICATION
OWNER OR � .Ce' / DATE / $ k