1985, 05-20 Permit App: 00005574 Furnacet -
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Ov ner's Name 13. , (First) (M)
`` k-11--1�
Department Use Only
Project No.
2 Project Address (Not Mailing Address) Space Zip
V3/ V /
- >_ d :Pr.-)
3 City/Community
WAS--
State
j '
I.J L's---
Subdivision/ Plat Name
4 Assessor Pa el No.
Lot
1 Block
5611
16 Contractor Firm�`� Name
Str Adddre?ss
ti
17 Zip
S I tt `
Cit
Staten
Phone ,,)-,-/02--5-•1-
18 Contact Person
License No.
Phone If different than above
8 Ow .. gent (if diYffferent than M1 above)
Busine
Address
9 Zip
City
State
Phone
15 Describe Work:
New Addition/Alteration 0
Replace/Repair ❑
10 Applicant Name,/
u..rr _ i o °v�
Street
Address
11 Zip
City
State
Phone
( )
8 VENT: Fan(s):
Evap Cooler (s):
Hood s):
Duct (s) 1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
I Range s):
Gas Log(s):
Wood Stove/
Solid Fuel:
Gas Water Heater(s):
11 UNIT HEATER(S): Wall Mount: Y N
Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. t.):
15 COMPRESSOR/ HP: Lessthan3:
3-15:
15-30:
30-50: 150+:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU: 57) / / S
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric ; Gas 0 ; Oil 0 ; Coa 0 ; Wood 0 ; Solar 0
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
APPLICATION )-z
DATE
�S
—�— DATE