1984, 10-02 Permit App: 00002603 Fuel Damper1-
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name �1(127/ ! (First) (M)
C"7 I- S r / 0
t'
Department Use Only �03
Project No.
2 Project Address (Not Mailing Address) Space Zip
S. /306 A' /e.�? 9,Z0�
3 City/Community ,/;
S (1K1%Ce,
State.
�
W K.
Subdivision/Plat Name
4 Assessor Parcel No.
Lot
1
Block
....
16 Contr tor Firm Name
62 qO
Q /7/7
Street Address r
.F/0 7100 .7de1 / u o -/mac.
17 Zipp
/
?
City
State
Phone
18 Contact Per n
.�
License No.
,,/
_323 j3c
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business
Address
9 Zip
City
State
Phone
( )
15 Describe Work:
New ❑ Addition/Alteration
❑
Replace/Repair ❑
10 Applicant NameStreet
/--,C0/--,C0//"//
� : /, s
5
Address
/30 6 Foy /ae
11 Zip
rV z.° 6
City
s,-�,�4e
State
c.
Phone
(5- ) fZ6r-/$.-660
8 VENT: Fan(s):
Evap Cooler(s):
Hood(s):
Duct(s)1:
Miscellaneo6y' 2 e ° O
10 APPLIANCE:
Dryer(s):
1 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: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. ft.):
15 COMPRESSOR/HP: Lessthan3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU: C" j) y e_74.:( / %Q�?�
( G/(
�t�,e,c 100,001 + BTU: /) 0
18 TYPE FUEL SOURCE: Electric ❑ ; Gas 011 0 ; Coal 0 ; WoodC❑0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air , 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 DATE
APPLICATION
*