1984, 11-09 Permit App: 00003287 Insert2
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name _ ( first)(M)
Department Use Only,
yl rC "%(Last)
/ % t (t /'✓f 'a /n- S l✓r e
Project No I
2 Project Address (Not Mailing Address)II Space ; Zip
N t 31c� o Ec� e r -f-c1-`--
3 City/Community,
c K-ct v1 'L
I State
I W c
Subdivision/Plat Name
4 Assessor Parcel Nd.
Lot
Block
32-81 rCj�J
16 Contractor Firm Name
Street Address
17 Zip /City
State
Phone
18 Contact Person
License No.
Phone if different than above
8 Owner/Agent (if different the 1 above)
Business
Address
9 Zip
City
State
Phone
15 Describe Work.
New 0 Addition/Alteration
0
Replace/ Repair 0
10 Applicanta
Street
I)
Address
j 3 lc O i= ser 4-
Cr-L''T_
i t,.. -.e tri- 1\ \C -Ke tt_.
11 Zip
9ce21a—
City
5 r e
State
ryok
Phone
(5D7 qa7-03c07
8 VENT: Fan(s):
Evap Cooler(s):
Hood 5).
Duct(s) 1.
Miscellaneous:
10 APPLIANCE:
Dryer(s).
I Range s):
Gas Log(s):
Wood Stove/
Solid Fuel
Gas Water Heater(s):
11 UNITHEATER(S): Wall Mount Y N
Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,000CFM or less. -
More than 10,000CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1000M:
14 1000-1750M'
Other:
Pressure Vessel (cu 1.):
15 COMPRESSOR/HP. Less than 3:
3-15:
15-30:
30-50:
504-:
16 GAS PIPING SYSTEM: Number of outlets: i
17 HEATING SYSTEM 1-100,000 BTU:
100,001 + BTU.
18 TYPE FUELSOURCE• Electric 0 ; Gas 0 ; Oil 0 ; Coal 0 ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION. Forced Air 0 ; Radiant 0 ; Heat Pump
1" Number of separate zones for any heating, A/C or air handling 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
Jits
APPLICATION //
DATE
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