1986, 09-04 Permit App: 00013430 Gas Piping_tea LI
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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PARC`L &-
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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 O p APPLICATION
OWNER OR ,�dV A.�.c DATE
Project
Owner's Name Last First MI
Project Address (Street Name & Number)
--. / 3 . 11,--c..4-0-,....... So -�
City
" ._
S2 CYkXio."-•!..,.:---------.
State
Subd ion/Plat Name
LtRrl —aRrc._ 0tkg i MS i.
w 4_— -
Assessors Parcel M/ -------.
/46 t i
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Lot
Block Plat #
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor
Ski/ I 714 /112-4-1-
.vqat
Address
G r0 d neo a it
City
1.1
State
A
Zip
c' du7
Phone
3a) S- `ir-/!
Contact
(S<,'(1
I License #
S1f yAt, /.l)S SnrS
Business Phone /r
Describe Work
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water I-Itr.
Solid Fuel/Wood Stove
Air Handling Units
0-10,000 CFM
10,000 + CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-103M
101-500M
501.1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-3OHP
30-50HP
i
50+HP
Gas Piping
1-5 Outlets
6 + Outlets
Gas Fired Heating System
1-100,000BTU
10,,,,;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 OF O p APPLICATION
OWNER OR ,�dV A.�.c DATE