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DOCUMENTSCITY OF BOYNTON BEACH DEVELOPMENT DEPARTMENT I BUILDING DIVISION 3301 Quantum Boulevard, Suite 101 • Boynton Beach, FL 33426 • (561) 742-6350 • Fax 742-6357 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. 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 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 rill out form completely. Owner's Phone # G 5T], 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 P Job Address: (including unit number and gate code, if applicable) Existing unit information: Make of Unit m Size (Gallons) C, Proposed new unit information: Make of Unit�p, Size (Gallons) ®P' Location of Water Heater: OVA Total Watts of Each Unit Heat Recovery Unit ❑ Total Watts of Each Unit Heat Recovery Unit ❑ /,v� ko A0 Yes No Yes 0 No om I certify that the information entered on this form accurately represents the system installed. Qualifier name (print) ce-� a_y- �� h License No.CrL I (I "A 9 ,(f!? Signature:&"ZVOL Phone No. _ �� q q.2� Cell Phone 3301 Quantum Blvd, Suite 101, Boynton Beach FL 33426 Phone: (561) 742-6350 Fax: (561) 742-6357 S:\Development\13UILDING\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) 11 NIZs IVES L COUNTY-WIDEIMUNICIPAL FOR OFFICE USE ONLY )BUILDING E IT APPLICATION FORM FBC Version: ' Permit Type: Accepted By: Application Date: //,Y/Z( 1uIV 2013 Edition Application #:_ Approved for use throughout Palm Beach County and Municipalities a z KIND of PERMIT (CHECK ONE): � PROPERTY OWNER: A Loa an6--- k TENANT: ❑ PRIMARY PERMIT ❑ SUB -PERMIT - if Fee & Value of a Sub -Permit are covered under a r� ADDRESS' _7 1 � P. ii'1 Yy del ,. UNIT' Primary Permit, complete boxes 1 3 4. S. 6 & 8 only to apply. If not a Primary Permit, complete the entire application to CITY' 1?1VA 4',-1'\ ti (',J�) STATE: :LLZIP:2 q 3 covered under apply. PHONE: 6 I 511 4 S 5 5 FAX: EMAIL: TRADE (CHECK ONE): PROJECT NAME: ❑ STRUCTURAL ❑ ROOFING ❑ ELECTRICAL ❑MECHANICAL tp�UMBING ❑GAS PCN: Q �_ y I_ q 5- a j__ � _ (9 o a _ 01 0 0 /❑FIRE OTHER' ) LEGAL DESCRIPTION: jhq; Anct,r_t6 Abb Lz iol A o / PRIMARY PERMIT #: r / ) 1 ADDRESS: o{ o� z a T I (fh RUQ Lm CITY: v o,� t N FURTHER WORK DESCRIPTION: ��c� qvh r!�? 0, Type of Work: ❑ New ❑ Addition Iteration ❑ Repair ❑ Demo ❑ Temporary ❑ Other VALUE: © 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. BOLDER): e� ��� License #: �tC, I q.2 y �p DBA (COMPANY NAME):_�)�1x.0 \PVN,A (bh�&rcc_CAtoi1 "i-ontact Person: Walt Abp 561 -Qag-I ADDRESS: �?Q(7 02 S W 4 y' I'\ STE:C_ CITY: STATE: A_ ZIP: PHONE: FAX: EMAIL: As m Application is hereby made to obtain a permit to do the work and installations as in Icated. l 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. (signature of Owner or Agent) (including contractor) Print Name: �f^�x,M Print Name:�tiY'r�t NOTARY REQUIRED IF $ 2,500 OR MORE, OR FOR ALL OWNER / NOTARY REQUIRED IF $ 2,500 OR MORE, OR FOR ALL OWNER / BUILDERS REG�RQLES$ OF $ Vgr{ UE STATE OF FLORIDA BUILDERS REGARD ESS OF $ VAL STATE OF FLORIDA COUNTY OF iiiP t��. � ,+'d COUNTY OF a 1►vt kj C� Sworn to (or affirmed) and subscribed before me this I— Sworn to (or affirmed) and subscribed before me this �_ day day of T ane' 20 2._ i . by of _ 'r-tz ,. 20V \ , by tha Y � ' G•-. (Name of person ent). 'P ,.•••., � � '� RAU (Nam din statemen . SWEID r o� Expires Jury 29, 2024 a°�' 025104 (Signature of Notary Public - State°FAf Florida) (Signature of Notary Public - St idaj E,Lpkes Jttly 29, 2024 (Print, Type, or Stamp Commissioned Name of Notary Public) nom, go libliq Nn(oet (Print, Type, or Stamp Commissio Ea amp B0°i�l�otary Public) Personally Known __Z'OR Produced Identification Personally Known '/OR Produced Identification Type of Identification Produced Type of Identification Produced Page 1 of 2