DOCUMENTSThe applicant is required to complete this form in order to receive a tum -around permit for an Exact Water
Heater Change -Out.
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. 1 also affirm that there is an electrical disconnect within sight and the water heater
is not cord -receptacle connected, meeting the requirements of 2014 NEC, Article 422 inclusive.
An electrical sub -permit may be required for any additional electrical work. All work shall comply
with the 2014 NEC.
Print legibly or type and fill out form completely.
Owner's Phone # 601 1
11 6555 -
Owner's Cell Phone # Permit Number:
New unit will be installed in what type of facility (check type of facility or fill in Other):
Single-family ❑ Other
❑ Multi -family
❑ Commercial
❑ Industrial
Job Address: (including unit number and gate code, if applicable) ap3 lvf-'
Existing unit information:
Make of Unit Total Watts of Each Unit
Size (Gallons) Heat Recovery Unit ❑ Yes ❑ No
Proposed new unit information:
Make of Unit Total Watts of Each Unit
Size (Gallons) n e�� Heat Recovery Unit ❑ Yes No
t b
Location of Water Heater: `� b :.. o ��
I certify that the information entered on this form accurately represents the system installed.
Qualifier name (print) Ce ,(- RU h
Signature: _k')&Z
WL
License No.
Phone No.
Cell Phone
3301 Quantum Blvd, Suite 101, Boynton Beach FL 33426 Phone: (561) 742-6350 Fax: (561) 742-6357
S:\Development\BUILDING\Forms-Templates-Signs\Water Heater Change Out Form 4-2017.doex
(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)
-1
UNIVERSAL COUNTY-WIDE/ MUNICI PAL
FOR OFFICE USE ONLY
BUILDING PERMIT APPLICATION FORM
FBC Version,=3 Permit Type: .Ma
Accepted By-:_ Application Date: �' 21
_//V�
July 2013 Edition
Application *t.
Approved for use throughout Palm Beach County and Municipalities
KIND of PERMIT (CHECK ONE):
PROPERTY OWNER: A kora rv\
TENANT:
o PRIMARY PERMIT
ADDRESS: UNIT:�&
o SUB-PERMIT - If Fee & Value of a Sub-Permit are covered under a
Primary Permit, complete boxes 1, 3 4, 56 " only to apply. If riot
CITY: 2 �/4 �� �® C,h STATE: ZIP:
covered under a Primary Permit, complete the entire application to
6( As�
apply.
PHONE: FAX:
EMAIL: k&614 a
TRADE (CHECK ONE):
PROJECT NAME:
Ei STRUCTURAL o ROOFING o ELECTRICAL
1 '0
PCN: 0
ii MECHANICAL LP-P61VIBING o FIRE o GAS
—
LEGAL DESCRIPTION: rh"W_arict�tvs
Ei OTHER:
ADDRESS:
PRIMARY PERMIT #:
CITY ao oo
FURTHER WORK DESCRIPTION:
Type of Work: o New D Addition (Iteration o Repair Ei Demo Ei Temporary o Other
VALUE: t f; r)O PERMIT FEE: NET S.F (for SFD's):
(SH FEE SCHEDULE) (AS APPLIES) (AS APPLIES)
❑ OWNER BUILDER PER FL. ST. 489 (AS NAMED ABOVE FOR CONTACT INFORMATION SEE BOX 2)
❑ CONTRACTOR (CERT. HOLDER): License#: Ly _Y8
DBA (COMPANY NAME):Nk 1&.4 \pv\"A GJy1S4rC'CAd-V\ 'filontact Person: W6th\ " A 50 -C(dq _q
ADDRESS: 9Q .2 cqk uf -_STE: CITY: _7 STATE: 'F' t zlp-_:;�
PHONE: Jaq-'Wqc� FAX: EMAIL: om
Application is hereby made to obtain a permit to do the work and installations as in icated. I certify that no work or installation
has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, and AIR CONDITIONERS, etc.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
!9
of Ctractor
tSia4ture on
(signature at owner or Aaent) (including contractor)
Print Name: Or,;��w Sa z
Print Ccsc"r V'(V\�(
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NOTARY REQUIRED IF $ 2,500 OR MORE, OR FOR ALL OWNER
NOTARY REQUIRED IF $ 2,500 OR MORE, OR FOR ALL OWNER
BUILDERS REGPRT�LESS OF $ V#LUE STATE OF FLORIDA
BUILDERS REGARD ESS OF $ VALLM STATE OF FLORIDA
COUNTY OF AA Lia, L d cAv_
-) e- tt c, L,
COUNTY OF L
,s°
I
Sworn to (or affirmed) and subscribed before me this
Sworn to (or affirmed) and subscribed before me this 4 day
day of T 20 2- by
of _(_/Z11 _J 20 by
(Name of person ff!�Odg sig nt)
CommWM#HHM5104
(Nam n kin statemen
AU $WEID
Expkes JUIY 29-2024
n
Commission
"OFIFlorida)r
(Signature of Notary Public - State 0
E;,pkesJ*29.2024
(Signature of Notary Public - Sta; Mtrloed
(Print, Type, or Stamp Commissioned Name of Notary Public)
,Oftida)
'N an
(Print, Type, or Stamp Commis id @a amelo"AaryPublic)
Personally Known OR Produced Identification
Personally Known ✓/OR Produced Identification
Type of Identification Produced
I Type of Identification Produced
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