1986, 07-02 Permit App: 00011932 ACMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
jL�Sd
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 L/ /
DATE
Project# ///,1
Last MI w
Owner's Name A4o//ei &(-i-S-7- r�11.
Project Ad ress (Street Name & Number)
/l/5'a i 15— iV: 13 a __, -.644,44.
Statg _A - q qa I) 4
Subdivision/Plat No,
Parcel #
Ap
(/�lL•/,
/65(/
1.---6/
Y
Lot t+`[
Block 2
Plat #
Applicant
Address
City
State
Zip
Phone
Business Phone
ntractorisiztAr
1/'^,/(J
Add /6
/
Cit
4# >, '
State
W4
Zi
47'q a /
Phon
'� -ato a
L
Bust ne
f ` 1
/ "1 04.4 1 13+ 13e-
Describe Work oo0
iA
e...4-62444444 OAR_ 44 adW'' °w
Fans
Evaporative Cooler
Hoods
Electric Furnace/ Ducts
Miscellaneous
Dryer
Range
'
Gas Log
Gas Water Htr.
Solid Fuel/Wood Stove
Air Handling Units
9,s. DAA
0-10,000 CFM
10,000+ CFM
--Refrigeration Systems/ n
Heat Pumps (BTU) 2q fJliiJ /✓(
7
1-100M
h
101-500M
501-1,000M
00/ -
1,001-1750M
Over 1750M
esaor
0-3HP
3-15HP
15-30HP
30-50H P
50+ HP
Gas Piping
1-5 Outlets
6+ • . =ts
Gas Fired Heating System
1-100,000BTU
10v,:00+BTU
\ '5
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 L/ /
DATE