1986, 11-19 Permit App: 00014283 Furnace, ACr
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
As
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 OF7 7/7
i� APPLICATION
OWNER OR i` c.a) I��'��1 ' .� �� .DATE Jf `�%C
Project # X283
Owner's Name iTh Last First MI
r��04 � � 7-,5 0 Ai 71/1 AJ M
Project Address (Street Name & Number)
'V 2 ` _ 1 ! , 7 j' �,
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City
C 414—
State ,
tom/ A
Subdi on/Plat Name
e gmeo A
Assessors Parcel #07 `
�J`
Lot
Block
Plat #
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor
/ /0/196C) /(,7-&—;' . ,' /v CC_
Ad s
o .51:5/ - ,;26---7-‘-'7
City
S m'4
State -
Com" /4
Zip
��/
Phone
.�..3v- `/�7
Contact
License #
Business Phone
DS�cnbeWork
//
Fans
Evaporativ Coder
/
Hoods
Electric rnace/ Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water H1r.
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 -31 -IP/ -
L
3-15HP
15-3OHP
30-5OHP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU �-
10v, 00+BTU
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 OF7 7/7
i� APPLICATION
OWNER OR i` c.a) I��'��1 ' .� �� .DATE Jf `�%C