1985, 09-09 Permit App: 00008083 Furnace, ACH
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name A, (Last) (First) (M)
Department Use Only �GFQm6
�1
'Ne- 1 'doh /U H-
Project No. v
2 Project Address (Not Mailing Address) Space Zip
L—' ff 7/0 (t.-1PA re 791{V
3 City/Community
40/A/Ve.
State
LOA-
Subdivl io IPIat Name
/4/R46EAti /4MC'H
4 Assessor arcel No.,Lot
c%5L/- (2/Qi
r
I Block
/L
16 Contrac or Firm Name �/
/1- °1—IV (��fA-l1 lV HcA r/�,/c
Street Address
E l Q7/a x110/AnV4-
17 Zip
7 q , 1 / Gc_Sr��A/up
/City
State
004.
Phone
( ) -9r2 g --r2./ btu
18 Contact Person
/-/) /i%e6-ho_,u5
/,
License No.
f- Q14NE-193N1
Phone if different than above
8 Owner/Agent (If different than #1 above)
Business
Address
9 Zip
City
State
Phone
15 Describe Work. (.t,Ltc` r --`l r2 re) /4\/C. u{'/{�yt__
I � New 0 ! Addition/Alteration 0
iLcd-:"{/C('-0'�/�[�4„t'Lv C L. V0.4.r
NA. (,
/ Replace/Repair f y/ Ui 6(6 �ks.-L.'
i10 Applicant Name
Street
Address -.lin
1
11 Zip
City
State
Phone
8 VENT- Fan (s)•
Evap Cooler(s):
Hood ):
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. 10,000 CFM or less:
More than 10,000 CFM.
13 REFRIG SYSTEM BTU: 1-1DOM: 42 9:......4,2/-
100-500M'
500-1000M:
14 1000-1750M.
Other:
Pressure Vessel (cu. t.):
15 COMPRESSOR/ HP: Less than 3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM- Number of outlets: A,4,4_,e_ 0 /✓ .(-tL7
mo//
17 HEATING SYSTEM: 1-100,000 BTU. — j
100,001+BTU: '
18 TYPE FUEL SOURCE: Electric 0 ; Gas 7K.; On 0 , Coal 0 , Wood 0 ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air y),„.; 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 tha
visions of laws and ordinances governing this type of work, including inspection requirements, will
plied with whether specified herein or not. The granting of a permit does not presume to give aut
violate or cancel the provisions of any state of local laws regulating construction or the perforr
construction.
SIGNATURE OF
OWNER OR
Atite:0Z
APPLICATION 6/ q Q
DATE // CC
all pro-
be corn-
iority to
ance of
•