1986, 06-02 Permit App: 00011726 Heat PumpMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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
ft%A fel r•n 1•
��J'11/ f _ /I l,7 /A
APPLICATION
Project" / / 72/C
Owner's Name Last First MI MI
Project Address (Street Name & Number)
:��U/G C!2i . i -Li /*f. .
Gly
State
S+Name
FARL L/ 0A-tv 2-A-/-0
Assessors Parcels
[/[-/, ` 57 2 3011 V
Block /
Plat
Applicant
Address -
C
Gtyl
I
1
State 1 ZI j.
lam,,-,� i `/ /73 7
Phone
q?,.. -g-'4-
/'rJ:'�C,C�!_;i
Business Phone
Contractor .-
( /7
Address
City
�/ i %tic
�
State J
`
�G%?,-..
Zip
l f? 7G•
Phone
,l,(r _e - 7 J�:-
Lie
- a/ — 2,1 Ai/
Business Phone
•
Describe Work `•,
Evaporative Cooler
Hoods
Electric Furnace/ Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr,
Solid Fusl/Wood Stow
Air Handling units
0-10,000CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)L�
1-100&1
[E t
101500MI
501-1,000M
1,001-1750M
Over 1750M
1 0-3HP
Compressor
1
3-1
t 1530HP
+
30.50HP 150+HP
1
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1.100,0I30BTU
10u0;00+ BTU
40 1/ ti
140
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
ft%A fel r•n 1•
��J'11/ f _ /I l,7 /A
APPLICATION