1985, 01-11 Permit App: 00003898 Furnace Al
• ... MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
OTSA - -5D-1/
1 Owner's Namet) st) (M) Department Use Only 7 y ,,
/61/ele�y ' ! Project No.
2 Prpject Address(Not Making Address) / Space Zip
[SAW Al . / Li (- 91 P
3 Cit /Comm nitS ateSubdivision/Plat Name
--Li- �f
4 •s essor Parcel No. Lot Block
O25 1 - 31
16 ;`tractor Firm Name (jt.,..{ Street Address
2 Ai , __
.-,._ ,,-.3-7 , ---7
1 1• City, Stat Phone
18 ., t Person License No. Phone if different than above
Tar , -t/-SF ' 47
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
i
15 Describe Work:
New ❑ Addition/Alteration ❑ Replace/Repair 0
10 Applicant e Street Address
n
11 Zip City State Phone
( )
* : *
8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: Miscellaneous:
10 APPLIANCE: I Wood Stove/
Dryer(s): Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
I-; 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
Z.
w
a 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
0
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
LL
0
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
CL
I-
0 15 COMPRESSOR/HP: Less than 3: 3-15: 15-30: 30-50: 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets: /
03
Z. 17 HEATING SYSTEM:1-100,000 BTU: ✓�C—'OM
�! ,f/�ary , 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gass y; Oil C ; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air X; Radiant ❑ ; Heat Pump CI
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- t\� )
visions of laws and ordinances governing this type of work, including inspection requirements, will be com-
plied
�1
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.
SIGNATUREAPPLICATION /. /I_�5� .
OWNER 0 _jd {j. /11-41-1"- i i DATE `�