1985, 12-20 Permit App: 00009210 FireplaceMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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 /246"
Project # 12 ( 0
Owner's Name Las Irst MI
je_-€4-7-2
et.
7
Project Address (Street Name Number)
/ 2. j --/-et----/— 79-z /
City
State
•
Subdivision/Plat Name
Parcel M
Lot
Block
Plat #
-/----le"-7c
7Z14--7%�t Q� d-7.-1-/22.
Address•
��/- -, d --x/
City
f
State l/
Zip
Phone
Business Phone
Contr,
et—ti
f"�- �
Address
City �S State
Zip
'72a7
Phone
/I3 -/b/7
• •
..ilf-f--/-1--
License #
k/,E-sr-,QTS - /9i(-'/'-
Business Phone
�.�-/e
= - •'= work
Fans
Evaporati . . ,
Hoods
Electric Furnace/ Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/Wood Sto,70
Air Handling Unite
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
0-3HP
3-15HP
15-30HP
30-5OHP
50+HP
Gas Piping
1-5 Outlets
0+ Outlets
Gas Fired Heating System
1-100,000BTU
10%,0300 + BTU
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 /246"