PERMIT DOCUMENTS
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CITY OF BOYNTON BEACH
DEVELOPMENT DEPARTMENT | BUILDING DIVISION
100 East Boynton Beach Boulevard--6357
_____________________________________________________________________________
WATER HEATER CHANGE-OUT
The applicant is required to complete this form in order to receive a turn-around permit for an Exact Water
Heater Change-Out.
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_______ I affirm that either a representative of my company or I have inspected the existing conditions
and there is no upgrade of the electrical system or service wiring changes required for the new unit(s)
being installed. I also affirm that there is an electrical disconnect within sight and the water heater
is not cord-receptacle connected, meeting the requirements of 2011 NEC, Article 422 inclusive.
An electrical sub-permit may be required for any additional electrical work. All work shall comply
with the 2011 NEC.
Print legibly or type and fill out form completely.
YYYYYYYYYY
672.858.6851
313.6:5.5268
Permit Number:
New unit will be installed in what type of facility (check type of facility or fill in Other):
Single-familyOther
y
Multi-family
Commercial
Industrial
2812Bsf{{pDjs-CpzoupoCfbdi-GM44547
Job Address: (including unit number and gate code, if applicable)
Existing unit information:
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Make of UnitTotal Watts of Each Unit
61
Size (Gallons)Heat Recovery UnitYesNo
Proposed new unit information:
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Make of UnitTotal Watts of Each Unit
66
Size (Gallons)Heat Recovery UnitYesNo
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Location of Water Heater:
I certify that the information entered on this form accurately represents the system installed.
Qualifier or (print)License No.
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Signature:Phone No.
672.858.6851
Cell Phone
100 East Boynton Beach Blvd, PO Box 310, Boynton Beach FL 33425-0310 Phone: (561) 742-6350 Fax: (561) 742-6357
S:\\Development\\BUILDING\\Forms-Templates-Signs\\Water Heater Change Out Form 8-2015.docx
(11/00,12/00,1/01,4/01,6/02,12/02,1/03,4/03,6/03,7/04,12/06,7/07,8/07, 01/09, 04/09, 01/10; 08/15)
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