1986, 10-30 Permit App: 00014035 Furnace, PipingU
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cam, ✓ MECHANICAL 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
OWNER OR
V L70, DATEAPPLICATION 7?,-77�/�
Project #
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Owner's
Owner's Name J t� ,
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Project Ad ss (Str Name & Number)
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City
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State
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Subdivision/ Plat Name
Assessors Parcel # \ �,O - /� �
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Lot
Block
Plat #
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor /
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Add ss _
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City
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State
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Zip
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Phone _
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Cont t
/A- .&7171°
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License #
.2i,-,3 z)2:./26ziG44/1- /7—,/i
Business Phone
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Describe • /
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Fans
Ev orative 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)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+1 -IP
_,----
Gas Piping ✓-
1-5 Outlets
6 + Outlets
Gas Fired Heating System
1-100,000BTU `/
10%,,,300+BTU
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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
V L70, DATEAPPLICATION 7?,-77�/�