Internet f145 11-2009 - State

1 1234567890123412345678901234123456789012 3412345678901234123456789012341234567890 1234123456789012341234567890123412345678 9012341234567890123412345678901234123456 7890123412345678901234123456789012341234 5678901234123456789012341234567890123412 3456789012341234567890123412345678901234 1234567890123412345678901234123456789012 3412345678901234123456789012341234567890 1234123456789012341234567890123412345678 9012341234567890123412345678901234123456 7890123412345678901234123456789012341234 5678901234123456789012341234567890123412 345678901234 mechanical INSPECTIONTECHNICAL SECTIONA. IDENTIFICATION APPLICANT: COMPLETE ALL APPLICABLE INFORMATION.

2 WHEN CHANGINGCONTRACTORS, NOTIFY THIS OFFICE. CALL UTILITY DIG NO: F145 (rev. 12/18) Internet versionFEE (Office Use Only)TOTAL FEES tate Permit Surcharge FeeMinimum FeeAdministrative SurchargeGeneratorFireplaceLPG TankOil TankHot Air FurnaceHot Water BoilerSteam BoilerGas Piping ConnectionsFuel Oil Piping ConnectionsWater HeaterFIXTURE/EQUIPMENTNO.$$$$Date ReceivedControl #Date IssuedPermit #Applicant: When submitting this form to your Local Construction CodeEnforcement Office, please provide one original plus three mechanical CHARACTERISTICSE stimated Cost of mechanical Work $Fuel Type:[ ][ ] Hot AirHydronicType:Use GroupR-3-or R-5 Present:[ ] Other[ ] SolarElectric[ ][ ] Oil[ ]GasHeating System work.

3 Modification to ExistingNewReplacementConversion[ ][ ]OR[ ]OROR[ ]123456789012345678901234567890121234567 8901234567890123456789012123456789012345 6789012345678901234567890121234567890123 4567890123456789012123456789012345678901 2345678901234567890121234567890123456789 0123456789012123456789012345678901234567 8901234567890121234567890123456789012345 6789012123456789012345678901234567890123 4567890121234567890123456789012345678901 2123456789012345678901234567890123456789 0121234567890123456789012345678901212345 6789012345678901234567890123456789012123 4567890123456789012345678901212345678901 2345678901234567890123456789012123456789 012345678901234567890121234567890678901 Failure Failure Approval InitialDATESINSPECTIONSType:Water HeaterApplianceChimney/VentPipingTankCoo ling/ACGeneratorFireplaceChimney SUMMARY (Office Use Only)PLAN REVIEWNo Plans Required[ ] mechanical Plans Approved[ ]Approved by:Date:SUBCODE APPROVAL for PERMITA pproved by:Date:SUBCODE APPPROVAL for CERTIFICATECA[ ]12345 [ ] CCO Other23456789012345678901212345678901234 5678901234567890121234567890 Date:Approved by:Joint Plan Review Required:[ ] Bldg.

4 [ ] Elec. [ ] Plumb. [ ] Fire.[ ] License No. Exp. DateFederal Emp. ID : Home Improvement Contractor Registration No. or Exemption Reason zip codemunicipalitystreetAddresse-mailTel. Owner in Fee: CodeWork Site Location D. TECHNICAL SITE DATADESCRIPTION OF WORK$Other _____Final _____ _____ _____ _____