1984, 08-03 Permit App: 00001754 Furnace1-
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MECHAMCAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) /(First) (M)
LE/GER FARC
Department Use Orli/—/f'
Project No.
2 Project Address (Not Mailing Address) Space Zip
C. /0202eoms 99. of
3 City/Community
-549/<AME
State
Lac .
Subd' n/Plat Nam
e fui1��U
4 Assessor �rcel'No. ,O. -B
"r eNam - '-
Lot
Bloc
2/
1 A/Q�//�
`/ /1
16 Contractor Firm Nam _ _
6ANNzR RNACE ¥ fLtEL Z. -
Street Atldre:
4/, / -2 /—kz:lf_ntit
17 Zip"-
992oa \
City
SPoK/*NE
State
14)4.
P .ne
(5oq) .5-3.57 7/1
18 Contact Person
• ' /.4196F
License No.
3 7yA/r
Phone If different than above
8 Owner/Agent (if different than 01 above)
Business Address
9 Zip
City `.1
State
Phone
( )
15 Describe Work: r'N9rAU-/NG .EN',^/ o.Y' O/x499—/os I/t rwQNAt!E
New ❑ \•` Addition/Alter ion ❑ Replace/Repair Al
10 Applicant Name \
Street Address
11 Zip
City
State
Phone
( )
8 VENT: Fan(s):
Evap Cooler(s):
Hood :
Duct(s) 1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
Range s):
G- Log (s):
Wood Stove/
Solid Fuel:
Gas Water Heater(s):
11 UNITHEATER(S): Wall Mount: Y N
Floo : Y
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 • M:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1 lit,
14 1000-1750M:
Other:
Pressure Vess- (cu. t.):
15 COMPRESSOR/ HP: Less t•an3:
3-15::
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Nu • ber of outlets: 1 7• CV
17 HEATING SYSTEM: 100,000 BTU: /„ ' i
100,001+BTU: 1=Tj,# - 5/"'bne) 4-66
18 TYPE FUEL SOUpCE: Electric 0 Gas 0 Oil Coal 0 Wood 0 : Solar 0
19 TYPE DISTRIB/{/UTION: Forced Alr 0 ; Radiant 0 ; Heat Pump \
I
1* Number of separate zones for any heating, A/C or air handling system.
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
OWNER OR
APPLICATION
DATE -Sc/