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Date: ���� (Card must be presented) MECHANICAL UNIT COUNT: Fuel Type (gas/other) Gas Dr er Air Handling < = 10,OOOcfm Fuel Tanks: t Length of gas piping � Renge Air Handling > = 10,OOOcfm Above Ground Furn <100K BTU's Gas Log Unit Heater Underground Furn >100K BTU's Fans Boiler BTU/H Miscellaneous Gas Hwt Hood Boiler BTU/H Other Conv Burner Duct Work A/C TONS Other DISCLAIMER: I eertify under penalty of perjury that the information furnished by ma n true�nd corroct to the best of my knowledpe and further that I�m authorized by tta owne�of the ebove premises to perform the wo�k fo�wMch permit applieation is m�de. I further prae to�ave Furmlesa the City of Fedanl Way a to any el�im lineludirp eo�t�,experxes and attwneys'fees incurred in investipation ard deferroe of such claiml,which m�y be made by�ny penon,includinp tM urxleniQned,and filed apairot tta City of Fede�ay W�y but only where sueh daim uises out of tM reliance of the City,ineludirq its officen�rd employeea,upo�tM�eeu��ey of the infwmation supplied to the City as a part of tMs�pplie�tion. ` v �� -9� Owner/Agent: � Date: