1987, 09-25 Permit App: FurnaceMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
tltY90 SO)e I�t! AS
3q -S
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 J
Pro,ect p 3 222.
Owner's Name Last J First MI
eii/J I 04M eAJ .e_
Project Address (Street Name & Number)
City A
State
i
SubdivLsionlPlat Name ADA
Ass or Parcel3 -3 3 15-
Lot
Blnk690, 0; 2 x7
��Y
Plat#
Applicant ;;& �I& s a
�o �N 2 �� i,Jcss
Address
.E g/03 r(c / ✓c�U
City�P-6
State Zip
G/a
q � 2_1� �
Phone r /^q (� 0
(�JY tC/y )l.�af
Business Phone
Contractor
Address
City
State Zip
Phone
Contact
License N
Business Phone
Describe Work
Fans
Evaporative Coo ler
Hoods
Electric Furnace/ Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
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
73Hp
3-15HP
15-30HP
30-50HP
5; HP
CG,,Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System T=1�
10x,:00+BTU
Nf tj Goqs-F_uxv c, o ode ` �,,) d& go ooci
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 J