1984, 05-22 Permit App: 00000686 Heat Pump•
MECHANICAL PERMIT APPLICATION WORKSHEET -// gm/r
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Lasst�)�/,/^ a/l (First) (M)
Le
t Vel?- -e-ifla, /-PAJitut
Department Use Only
Project No.
2 Project Address (Not Mailing AddressSpace Zip
//, 54 g) ' /4'zn^/— Yge: 6
3 City/Community
State
Subdivision/ Plat Name
PQ d es
4 Assessor Parcel No.
/6,54/- CSe/Z
Lot
/
Block
I/
16 Contractor Firm Name /
G
Street dress
17 Zip
City
State
Phone
18 Contact Person
u0lf-a
License No.
- '-1
57.t/r,.
Phone if different than above
8 Owner/Agent (if different than 11 above)
.i2.-.2/ 01
Business
Address
g Zip
City
State
Phone
( )
15 Describe Work:
New i3' Addition/ Alteration
0
Replace/Repair 0
10 Applicant N e
A ' A 1 �.r
Street
Address
7/5/u C /x,15
11 Zip
City /
State
Phone
-8 VENT: Fan(s):
Evap Cooler(s):
Hood(s):
Duct(s) 1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
1 Range s):
Gas Log(s):
Wood Stove/
Solid Fuel:
Gas Water Heater(s):
11 UNITHEATER(S): Wall Mount: y N
Floo
: Y N
Suspended: Y N
12 AIR HANDLING: 10,000CFM or less:
More than 10,000CFM:
/13
REFRIG SYSTEM BTU: 1-100M: &At,
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. t.):
15 COMPRESSOR/HP: Less than 3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU:
100,001 + BTU:
, /
18 TYPE FUEL SOURCE: Electric E'; Gas 0 ; -011 0 ; Coal 0 ; Wood 0 ; Solar ❑
li
19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant 0 ; Heat Pump/
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
ll,%_ (xY�x- CATION
DATE