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� Da;e:,.__� =22 —� � <br />Applicatbn/Petmit / <br />� Owner.�L'��i <br />� SAt Addmss __� a <br />�Assessor's Px <br />, Site Address <br />�—'---X lAU.i�� �'_� <br />rty Tax_Account No_ <br />No, o$9.Io�S3 <br />.....� a.a.�.........�s..a�...(�.-� <br />o .,,.. _ _ . _ <br />OwnePs Addrea� <br />BuiWer N� r,. <br />Address <br />Zip <br />Phone <br />IIE310ENTIA <br />; � Ciry...f:�'1.(!�1%'�..\4.�S.1.�..L.%.�..�'r .................................................Zip.....1`�..If...7...7Ci.....Phone....�a..`..z...,�..-.tr�.,`'..t...��.................. <br />• <br />� M��II�II�Y���� <br />• . <br />• <br />• PpOJECT DESCHIPTION: <br />� O New d�ition �� cj inple Fami y / ol Storias...Z........ <br />�Q Remodel G Cond'Aioned SQ. Ft .................... O MuMi-Famiy / ol Unita......................... <br />FUEL SOUHCE: HEATING SYSTEM TYPE: • <br />O Ekctrfc O Basebwrd p Heat pump HSPF .............................. <br />� O Oil O W hrater O Other ................................................. <br />. O Gas urnace AFUE ................... O Total installed watts or BTU's ............ <br />• <br />. <br />. <br />•��������������������������������������.���������������� <br />Check one ol b� CompGmu Optlon Boxes below. IMert the wlues inro boR number 1. &lore comqetinp IhB <br />ced'wn rtler W the Instructiorx on bock ol form. <br />Eleetrie • Morthwect Enarqy Code, <br />Ch�pt�r 6 <br />Q Wtll Insulated Floor O Systems Analysis, <br />Option �C 'pter / <br />O Well Iosulated Wall (9'Component PeAormance, <br />Option Chapler 5 <br />O PassNe Solar Option O C^mpener.t ?oint System, <br />O Heat Pump Option Chapter 7 <br />FOp DEPARTMEN7 USE ONLY: <br />AmouM of Paymen(.5..:. .:.:.:... ......:'; <br />Date Permit Issued .....::: ........: ........:' <br />� Date Permit Fnaled....... ..._...:_ .......:: <br />1 herehy certilythat Ihis dwellinp was buiR in <br />compliance wrth the NWEC. <br />..:.:...:»......_ :.:...................:...........:.....:..._........... <br />�� ��� Buibinp 011iwl or AuNorind ApeN . <br />......«.. ..... .... .___..... ._...:..... <br />D�le . .. . . .. .. <br />Olh�r Fu4 Sourcu - <br />W��h(nqlon St�l� Enarq� Cod� <br />0 Prescriptive ADProach, <br />Chapter 6 <br />O Component PeAormance <br />Approach, Chapter 4 <br />O Systems Anaysis, <br />Chapter 5 <br />COMPONENT <br />Flat Ceilinp R.:� 8, <br />Vaulted Ceilinp R........... <br />Wall R.. Z.�. <br />Below Grade Wal�: <br />inlerior R............ <br />exterior R............ <br />Fioor fl.......—..� <br />Slab on Gnde R............ <br />Uoora 8 Fnme U.......— <br />Glazinp U.,..� <br />%Glazinp .�.�...% <br />SolarAllowance-/ ...........% <br />AirLmkaqe �STD OADV <br />•�••••�.•• <br />I hercEq urtifv thil tl�e slNCNril pmels will mee� Ihe NWEC Fortmkehyde rtpuiremenh -eiNer Ihe <br />HU� st�nduds or madced'eateriof or'ecposure 11 .. <br />Ownet orllolfiorli�d Aqenl: <br />..................................................................... ................................................................... <br />Print Nune Sipn�Wrc <br />iAe loal jurisdktlmkleciric u61iry will m�ke a p�ymenl to eitl�er tl�e builderoroxnerior neweleUtir�Ry <br />heoled residenas. Permil musl be issued by 17/31A1 +nd conBrucEon fin�kdpy 6/3092 in order lo <br />awlily 1or Wyment. To qcili�te D+Ymm� Ihe toAawinO inlorm+don mutt M filkd oW eanpktdy. <br />M�ilthecklo:(pk�seprinq (ADDITIONS/RC-P10DGLS NOT ELIGIBLC) <br />Name................................................ Fed. Tac ID ar SSI...................................................... <br />Address <br />Zip.......................................... <br />HOiF� M IPS Fartn 1099 �.+A M unt ll C�e en0 d Ae �e+r. <br />