1987, 05-21 Permit App: 87001524 Water Heater MECHANICAL PERMIT APPLICATION WORKSMEET
?LEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project# e"7� !z`
Owner's Name r., Last First MI A
c e, '1\`C-,L cI\I<-� ---‘4:PI S 4)VV)
Project Address(Street Name&Number) 1
E , \ \C; rl-.\\e. � 0x 3 c I
Cit State y Subdivilion/Plat Name
Lot Block Plat#
Assessors Parcel#
Applicant V\ Address _
City 1 State \ Zip { /� Phone
-ICA.—% ` \.C,aC3 5 - �i33 ' 1.--SD
Business Phone
Contractor_ Address �� n
\ ) , \ \ cz_y-s'\c_..\/3 \t3 s-7 - \ .,si___
State Zip Phone
City — �•,) 1, C "0103 s3s-- 1-1 s-- 9-�
�_� License# `._)L/Q-1 Business Phone ,
Contact �^-�� \ `;
v'c-`"._ V*1t ,ick 9v G-" -\ c 1,7•6c C s' 3 - ��J a
Describe Work —j ----...,,,)
.k;) 6-Ap\m_r_...re-__yrn.Q_Nik... .._... Ges.:-. .$-'- c,--\'a-' kz4V-1---:ck\-e-t—
Fans Evaporative Cooler Hoods —ET€CThc urnaoelDucts Miscellaneous
Dryer Range Gas Log Gas Water Htr. Solid Fuel/Wood Stove
0-10,000 CFM 10,000+CFM
Air Handling Units
Refrigeration Systems/
1-100M ---_. 101-500M 501-1,000M
Heat Pumps(BTU)
1,001-1750M Over 1750M
0-3H P 3-15HP 15-3OH P 30-50H P 50+HP
Compressor
1-5 Outlets 6+Outlets
Gas Piping
1-100,000BTU 10x,:.00+BTU
Gas Fired Heating 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 corn-
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. ' r
SIGNATURE OF `\ ----7-----7 ) APPLICATION/d.)OWNER OR `----..1.