1985, 02-05 Permit App: 00004167 Water Heater .. .—
•
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name �/,(Last) ��.. (First), (M) i Department Use Only 1'
�1,/ %jam-1_,- ,/� - 7‘.-e1/-4-- 4;� 1 Project No.
2 Project Address(Not Mailing Address) / Space Zip
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3 City/Community /,State Subdivision/Plat Name
• �U 5W( mt V
4 Assessor Parcel No. Lot Block
0Y ?- - 0P
16 Contractor7 ContractorName Str t Address
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, ----)-6-7,4. /...-' `/ /i P - '3. 71 • 77)17
17 Zip Ciity� State Phone
18 Contact Person License No. Phone if different than above
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work:
New ❑ Addition/Alteration ❑ Replace/Repair
10 Applicant Name Address
11 Zip City - State /— Phone /l
*
8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: Miscellaneous:
10 APPLIANCE: Wood Stove/ /,--(7-__..--
Dryer(s): Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s): /'i' ',2)
11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
Z
W
2
IZ 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
5
0
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
LL
O
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
CL
>I-
0 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets:
CO
2
Z 17 HEATING SYSTEM:1-100,000 BTU: 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas7/1 Oil ❑ ; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant ❑ ; Heat Pump
6fty1* 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 �. 4) , ��� APPLICATION- ) —,,/l_ DATE