1986, 11-14 Permit App: 00014153 Furnace, PipingMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1
Owner's Name Last)
. (First)
(M)
Department Use Only
Project No.
2
Project Address (Not Mailing d ress
e N
Space Zip
3
City/Community
State
Subdivision/Plat Name
4
Assessor Parcel 00.
Lot
Block
16
Contractor it% Name
Street Address
/ �J /
17
Zip
City
.5,p
State
4e-4 /j
Phone
c ) 3
18 Contac ersonn.� J
License No.
4 0/:k= / / oc
Phone if different than above
8
Owner/Age t (if different than 81 above)
rusiness Address
g
Zip
City
State
phone
15
Describe Work:
New
Addition/Alteration ❑ Replace/Repair ❑
10
Applicant Name
Street Address
11
Zip
City
State
Phone
8
VENT: Fan (s):
Evap Cooler(s):
Hood(s):
Duct(s)1:
Miscellaneous:
10
APPLIANCE:
Dryer(s):
Range(s):
Gas Log (s):
Wood Stove/
Solid Fuel:
Gas Water Heater (s):
11
UNIT HEATER(S): Wall Mount: Y
N
Floor: Y N
Suspended: Y N
12
AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13
REFRIG SYSTEM BTU: 1-100M:
100-50OM:
500-1000M:
14
1000-175OM:
Other:
pressure Vessel (cu. ft.):
15
COMPRESSOR/HP: Less than 3:
3-15:
15-30:
T30-50:
50+:
16
GAS PIPING SYSTEM: Number of outlets:
C/
17
HEATING SYSTEM: 1-100,000 BTU:
p G'i>U T�
100,001 + BTU:
18
TYPE FUEL SOURCE: Electric ❑ Gas Oil
❑ Coal ❑ Wood ❑ Solar ❑
19
TYPE DISTRIBUTION: Forced Air;
Radiant ❑ Heat Pump
1* Number of separate zones for any heating, A/C or air handling system. Zl
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 / APPLICATION
OWNER OR DATE !� %
'/