1985, 08-07 Permit App: 00006739 Heat PumpMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
I certify that the above information as submitted by me is true and correct and further, agree that all pro-
visions of laws and ordinances governing this 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 of local laws regulating construction or the performance of
construction.
SIGNATURE OF?[z
OWNER OR /
APPLICATION r�
DATE fi 7 --
Pro ect #'�
j
(r.:—/-) V
Owner' Name LastFirst , MI
, /r, SC, o 0 -7. --ti ,to, l
Project Address (Street Name & Number)
$ ,P— s / - ,do /i via- /
Cit
,!'/ly 4 (�,
State
y� G / 1 • •
Sub isionn//i Plat Name f�
J L / 04i. AJ A"op/
Assessors .P�arcel # �-
.245 4LZ — /5 2
Lot
.5
2.5-
Block
a.
Plat #
Applicant �/ ,,/� ('
4 / /! ez.-1�,.1 .1 c 4L Je�� Y/ <- ,
Address
$3 3 ,.✓ j'9li jr '
City/
/C ti. ^- L
State,A.
"V
Zip
% moi' :%t,
Phone j
Business Phone
01� r" , 3 Y r eT
Contractor
�/ S X � �
X %/ 71-774
Address
5 3,E 3 A, l�, fCit'
5y ,e/it." 4 .A. -,...-State
n
Zip r
Phone l 5. --
& tact
Li nse #
A 1r-1 J ie l 6"-
Business Phone
1- J134,1"
Describe Wor
'e/ .C. 7( ri f /6v --I-y/ ,/J
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/Wood Stove
Air Handling Units
0-10,000 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU) 3a d° Gi
1-100M
101-500M
501-1,000M
./
1,001-1750M
Over1750M
Compressor
0-3HP
3-15HP
15-30HP
30-5OHP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
1Q,,;,00+BTU
I certify that the above information as submitted by me is true and correct and further, agree that all pro-
visions of laws and ordinances governing this 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 of local laws regulating construction or the performance of
construction.
SIGNATURE OF?[z
OWNER OR /
APPLICATION r�
DATE fi 7 --