1986, 05-30 Permit App: 00011643 AC.e± (, Vit,
MECHANICAL`PERMItAPPLICATION;WORKSHEET
PLEASE. PRINT: AND: COMPLETEONLY THOSE FARTS OFATHE FORM ¥OU UNDERSTAND
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Protect w % /in l
f • .-4� L Y
OWnar'e Name - `Last •FEr�t,,•,,//•.�' :•.!!`'•;
Project Address (Street Name & Number► - •;>',•.`'
3,575 A/ /3'. )A 7 :;',. ,.. . .
City
Q
.Bubdlvlalon)Plat Name
Asacssors Parcel N^
• �:'
.Lot••'
-Black -. !Plat,
AppItcani / - �. I
' �� .
- . ,. . •. -
Address
City .
• State,
.: - -
�'9.�'—f3vr7
,.
BUsineas Phone
Contractor
/34/141447;‹/71/ /5– C..11;
.,, .
Address .or ma c «
City
...14011 44(
State :
�I' /® ;.
Phone .....4.---2.4--,-/ 7//
//
Contact -1
&74-///////7/17-4/),LA/0/p/
Lloense a
;�rdA✓,�/.e774 q a' '-
Business Phone
• g
Oe3crtbe Work •
. i,Vj7 L/— % /}/,<' di; 1/0 4,ioK/- ,(70. ,
Fane
Eveporetive Cooter
Hoods
•
Electric Furnace/Qucts
Miscellaneous
Oryer
.Range :
Gas Lop'•:, `...
Gas Water Htr. •
Solid Fuel/Wood Stove
Air HandfingUnits,
0.10,000 CFM ' • '
y
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
�j-
1.1 M� d /�a��(�J"
A//YirKW.✓//.. '.:::'
:101-5OON
, • '
501-1,000M
.1,001.1750M ,:
Overl75OM ;.` .
Compressor
0-311P/
Y
3-15HP ' '
1b3OHP . •
30-5OHP
50+HP
'
Gas Piping
..-5 Outlets6
- `
i Outlets
'Mr,
Gas Fired Heating System
1.100,OOOBTU ' •
# BTU
•
i 9:
•
. :. - .,. , ...r i ;: c :,�5',:,. •:.: ...
'• "f.'':F `I tip: •- .
I certify that the above lnformatIIon`as."submltted:by rne.Is'true and correct and further, agree that all pro-
visions of laws and ordinances governing thls,type-of work; including inspection requirements, will be com-
plied with whether specified herein or not: The granting of a permit does not presume to give authority to
violate or cancel the provisions of any state ofIocal laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR
APPLICATION �'
DATE.