1984, 10-29 Permit App: 0003158 FurnaceECHANICAL I' :RMIT APPLICATION WORKSHEET
PLEASE PRI NTAND COMPLETL ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last), (First) (M)
Department Use Only
///6.:Y r ' - s Air
Project No.
2 Project Address (Not Mailing Address) Space . Zip
-:)..3 /V• , lt/. ..
3 City/Community /
>:< -
State
//
Subdivision/Plat Name ._,
`_ tt 061 tY, 1 fes,' til' - /l ! '(1(7e/1
4 AssesaoS 0
Lot?
Block `
18 Con iFkm N1inN y 4 tµ
Ar a fi.9+ �, M'�•i.
�y�%FSi'x
k -
�.'
Street dress
f' c / "1')G /7/,‘
1.7.1.Z.
'#,r r r y" T :e.'�.
# �7/ °'
State,
,.1.'4,-,r(4- -
Phone _
✓77/)...c37'--/7//
18 ContactPerson
f G?i� :a +.r✓;
° .
�' Y�sa4f?
Y
Ucense No
eshWJ'�
'p/_
Phone If different than above
8 Owner/Agent (If different than N1
',1 +pis
Business Address
9 ZIP `jva,n t
pity
State. •
Phone
( )
15 Detcrtbe Work: ` - 7l/./-: /`'//'J 7,IF 4l t 'Zr-L;7--
='/ ,rt "— 7,, j ,L...‘- New- 0 Addition/Alteration
/A
❑ Replace/ Repair X
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( 1
8 VENT: Fan(s): `
Evap Cooler(a):
Hood e):
Duct(s) 1:
Miscellaneous:
10 APPLIANCE:
Dryer (s): ,
Gas Log(s).,3+.,,4 ,n :_
Wood Stove/
. Solid Fue :
Gas Water Heater(s):
a ,{ytvA++taw'""
11 N om"
lt '� 1`.°iE;�w m �'�.,roer
.'c a 4 a a :t
>rA0t�1t x,�i 3s-w#�'�y
.� -4 ?k�.+}x ? � t. , ix'e#
a�''"
� ,ry' 14.1:::000m:, Suspended: Y N
� i :,�
, .b
°n Wit
ia.. $'4,tts
�00M
17'. era i a
A tivis`titt'•k�l - 4w tksn
yz 99 1"
tet � a
`. c
� 1attg
-',x✓ "'s '� -� �., a. ry^h�i '
100�1T50M
> A
•(• PPP@��
'% ayy gci
4`.
k
Ture Vessel (cu. t.):
ev 4
- ISA
. 4¢f t 1 �z Lesetk
I #,�
30 50:
50+:
y t , .ry .f
i8 GAB PIPING SYSTEM: Number of outteta:' -;t'
- ,/e'-''.1:-.-,
17 HEATING SYSTEM: 1-100,000 BTU ! _AIA/Z` }'. Ci/�' ;��/
100,001 + BTU: /4 e%'e�)
---
18 TYPE FUEL SOURCE:Electric O ; Gas ❑ ; Oil -, ; Coal : ❑ ; Wood ❑ ; Solar 0
19 TYPE DISTRIBUTION: Forced Air Radiant G) , ', Heat Pump
1* Number of separate zones forany heating; A/Cpi'
andling system.
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,
OWNER OR •,
APPLICATION
.DATE l