1985, 11-12 Permit App: 00008671 Insert7,)
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.SIGNAT�' �jfj��%
OWNERUORO//J—u�v/,�/✓�X DATE
/S�
Project tt A7`1/
lO
Owner's Name Last First MI
72-68
144„,
Project Address (Street Name & Number �,
e, 7 cr.,' i /CZ,2-
City Ftate
-rn/-�.�i+ l4%4.1,..rc.iru l
Subdivision/Plat Name
AG -Su i�
Assessors Parcel qLot
X2.53,, - cnis
Block
-
Plat p
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
License It
Business Phone
Describe Work '
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/Wood Stove
Alr 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+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Healing System
1-100,000BTU
1P,,,;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.SIGNAT�' �jfj��%
OWNERUORO//J—u�v/,�/✓�X DATE
/S�