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<br />Owner _J� l._� �_�L�.B�--------�_.�r
<br />SNe Addrea� ....�.%.�q? --_� _..... .._..� .,��Y�S�?
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<br />Owner'�Addnn ......... ... .!:.�L................................,........... C
<br />Ny .................................... Zip .................... Phone ...................................
<br />Bullder.............�.CJ�.�.`..!� .....................................Addrw�........- .._
<br />CNy
<br />PH�OJaE�CT OEECRIPTION:
<br />O Remodel
<br />fUEL,OUqCE:
<br />C�bA�lc
<br />O 011
<br />dEilbn
<br />O CondNbned 6a. R . ....................
<br />NEITINQ !Y{TEM T1'pE:
<br />O BnebraM
<br />• �II heater
<br />• O Oe� O FurmceAFUE ...................
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<br />•.�����.���r����a���•
<br />�D
<br />Phone
<br />�e F�mly
<br />O MuA!-F�miy
<br />/ ol Slorke ......................
<br />/ ol Unit� .........................
<br />O Nmt pump HSPF ..............................
<br />OOlher .................................................
<br />O Tolel In�WBed ws1t� or BTUY .,,.,,......
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<br />CINCII OIN OI �IY CMIFAi11G OpBql SOIH MI01►. IMf1i IIM VIIIMt IIIIO EOM IIYIIIMf I. MI011 WIIIq11� b
<br />aetlan nhr M IIN hMnietlan�on bxk al Porm.
<br />ENelrle • Npthw�l En�ryr CM�,
<br />Chg Iw1
<br />f�'Weli In�ul�led floor O 6y�Um� Andy�h,
<br />Oplbn CMpter �
<br />O W�ell In�ulal�d W�II O Cohmpof 6nt P�Aormenee,
<br />0 Ibn p
<br />O Pa�eAi 6olu Oplion �J Componertl PolnlByetem,
<br />O Hat Pump Oplbn Chepter 7
<br />FOR UEPAqTMENT UdE ONLY:
<br />Amoum ol PaymeM = .:..................
<br />Date PermA beued ................................... .
<br />Dale Permit Flnaled,,,,,,,,,,;,,;,,,,,,
<br />I hereEy cert(ry Ihal thh dwelllnp wae bulM In
<br />compliance whh the NWEC,
<br />..... .....:...... _,.....,..,.......:......:................... _.
<br />BuIIdMp 011kql or AutAo�lnd Apent .......... �
<br />U�Y :. .................................... ._._............
<br />Olhn Fnl twrat -
<br />Wnhinpan qd� EnNry CW�
<br />O PraerlptN� Appro�ch,
<br />Chapter 6
<br />O Component pedormance
<br />Approech, Ch�pter �
<br />U 6yetem� Analy�h,
<br />Chepter 6
<br />COMPONENi�
<br />Flel CeiIInO q.,��„�}
<br />VaWled Cellinp q.,,,, ,,,,,
<br />WaN N..%.�..f.
<br />Bebw Onde Watl: �`� "� �-
<br />MlKlor R............
<br />uAxlor N............
<br />Floor q„�,
<br />Blab on Onde R............
<br />Doon 6 Fame U.,t..-',
<br />OleZh19 U..r � 0
<br />%Olulnp 1.7��,%
<br />SelerAlbwence .,,,,,.,.,,%
<br />AhLmkape (�SiD OADV
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<br />I MnbY arllfy lul w� �IruoNql MnY wIN mNl M MNEC Feimddrhyd� nCWmnrnb • Ntlw M
<br />NUD tfmdua ernqrMd yabAnf or yipaun 1'
<br />ONnw a Aiil6arinl A�ml:
<br />......... ............................................................ ...................................................................
<br />Pfil /lma 6qn�dn
<br />TM lonl wAWktlanhlecl�k utllly wNl m�k� ���yme 11� lo �Ilh�f M bWIM/0f OwMf (Of MNIIICIIk1�
<br />ha�ed mNena�. A�mN mur N b�uedb� 17/31A1 �M eonNutlon 6Ynl�by dJUAt In ordw b
<br />ImIMy la pyminl. Ta InNIbY WYmml, fN lollowlnp Inlorm�tlan mu�l M AINd eul eempNWy.
<br />MNItMekla:�pNiaepdnp (ADDITIONS/RC:MOUELS NOT ELIGIBLE)
<br />Name................................................ Fed. Tu 10 or SSI......................................,...............
<br />Addreu................................_ _
<br />CNy....................................................................................... Zlp..........................................
<br />...��..�. . � . �. ., � . . .. r.� � P/p�!' �! ".f^ ..�.... � �
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<br />NOIE: M IR! /emi fOp M M wrn M M�n1 M M ypr.
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