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PERMIT NO._ LICENSE NO.. APPLICATION FOR HEATING PERMIT (Application must be typed or printed) TOWN OF LYME CONNECTICUT LOCATION OF JOB (NO. I STREET) MAP LOT OWNER ADDRESS (NO. STREET, TOWN, STATE, ZIP) PHONE HEATING CONTRACTOR ADDRESS (NO. STREET. TOWN, STATE, ZIP) PHONE REMARKS APPLICANT ADDRESS (NO. STREET) TOWN, STATE. ZIP Town Fee: $15.00 for 1st $1,000.00 $10.00 for each additional $1,000 or part State Fee: $0.26 per $1,000.00 TYPE OF INSTALLATION D HOT WATER D HOT AIR D VENTILATION D SPRINKLER D STEAM D AIR CONDITIONING D INCINERATOR D TYPE OF WORK BEING DONE D ORIG CONSTRUCTION DREPAIR D ALTERATION D DEMOLITION D ADDITION COST FEE CLASSIFICATION USE GROUP CONSTRUCTION TYPE. SPECIFIC USE ESTIMATED ACTUAL DIFFERENCE ADDITIONAL nil Permits Must Be Posted And Visible From The Street BOILER OR FURNACE MAKE. MODEL INSP. NETBTUH. GPM DOMESTIC HOT WATER. BURNER MAKE. MODEL GPH INSP CHAMBER SIZE TANK LOCATION. SIZE FILL SIZE VENT. SIZE INSP. —gal. .in. .in. PIPES NO SIZE MAIN CIRCUITS ZONE I.B.R. HEAT LOSS SCHEDULE Heat loss must be complete for all jobs. Work sheets may be attached. COLA 10 12 ROOM ROOM DIMENSIONS. FT. LENGTH EXPOSED WALLS. FT. WINDOW AND OUTSIDE DOOR AREA WALL CONSTRUCTION TYPE OF GLASS CEILING CONSTRUCTION FLOOR CONSTRUCTION 1 COLD PARTITION CONSTRUCTION ONE WALL (with glass or exterior door) TWO WALLS (with glass or exterior door) £ THREE WALLS OR ENTRANCE HALL(") TOTAL BTUH AT TfTF TEMP DIFFERENCE- TOTAL BTUH AT DESIGN TEMP. DIFFERENCE COL. B IX o < COL.C H L W COL. D H L W COL. E H L W COL. F H L W ROOM TOTALS RADIATION FROM LINE 12 SELECTED TOTAL BTU OF BUILDING AT DESIGN TEMPERATURE DIFFERENCE TOTAL RADIATION SELECTED * increase bathroom total 70% t for concrete floor on ground or fill at grade level, use linear feet of ex- posed edge. All work covered by this application has been authorized by the (owner) or (agent) of this property and will be done according to state regulations. This permit shall lapse If work ooes'not commencewithin 6 months. Dale Applicants Signature D APPROVED Date O DISAPPROVED BuHdtng Official

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Page 1: nil Permits Must Be Posted And Visible From The Street

PERMIT NO._LICENSE NO..

APPLICATION FOR HEATING PERMIT(Application must be typed or printed)

TOWN OF LYMECONNECTICUT

LOCATION OF JOB (NO. I STREET) MAP LOT

OWNER ADDRESS (NO. STREET, TOWN, STATE, ZIP) PHONE

HEATING CONTRACTOR ADDRESS (NO. STREET. TOWN, STATE, ZIP) PHONE

REMARKS

APPLICANT

ADDRESS (NO. STREET)

TOWN, STATE. ZIP

Town Fee: $15.00 for 1st $1,000.00$10.00 for each additional

$1,000 or part

State Fee: $0.26 per $1,000.00

TYPE OF INSTALLATION

D HOT WATER

D HOT AIR

D VENTILATION

D SPRINKLER

D STEAM

D AIR CONDITIONING

D INCINERATOR

D

TYPE OF WORK BEING DONE

D ORIG CONSTRUCTION D REPAIR

D ALTERATION D DEMOLITION

D ADDITION

COST FEE

CLASSIFICATION

USE GROUP

CONSTRUCTION TYPE.

SPECIFIC USE

ESTIMATED

ACTUAL

DIFFERENCE

ADDITIONAL

nil Permits Must Be Posted And Visible From The StreetBOILER OR FURNACE

MAKE.

MODELINSP.

NETBTUH.

GPM DOMESTIC HOT WATER.

BURNER

MAKE.

MODEL

GPH

INSP

CHAMBER SIZE

TANK

LOCATION.

SIZE

FILL SIZE

VENT. SIZE

INSP.—gal.

.in.

.in.

PIPES

NO SIZE

MAIN

CIRCUITS

ZONE

I.B.R. H E A T L O S S S C H E D U L EHeat l o s s m u s t b e c o m p l e t e f o r a l l j o b s . W o r k s h e e t s m a y b e a t t a c h e d .

COLA

10

12

ROOM

ROOM DIMENSIONS. FT.

LENGTH EXPOSED WALLS. FT.

WINDOW AND OUTSIDE DOOR AREA

WALL CONSTRUCTION

TYPE OF GLASS

CEILING CONSTRUCTION

FLOOR CONSTRUCTION 1

COLD PARTITION CONSTRUCTION

ONE WALL (with glass or exterior door)

TWO WALLS (with glass or exterior door)

£ THREE WALLS OR ENTRANCE HALL(")

TOTAL BTUH AT TfTF TEMP DIFFERENCE-

TOTAL BTUH AT DESIGN TEMP. DIFFERENCE

COL. B

IXo

<

COL.C

H L W

COL. D

H L W

COL. E

H L W

COL. F

H L W

ROOM TOTALS RADIATIONFROM LINE 12 SELECTED

TOTAL BTUOF BUILDINGAT DESIGN

TEMPERATUREDIFFERENCE

TOTALRADIATIONSELECTED

* increase bathroom total 70%

t for concrete floor on ground or fillat grade level, use linear feet of ex-posed edge.

All work covered by this application has been authorized by the (owner) or (agent) of this property and will be doneaccording to state regulations. This permit shall lapse If work ooes'not commence within 6 months.

Dale Applicants Signature

D APPROVED

Date

O DISAPPROVED

BuHdtng Official

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