1984, 10-18 Permit App: 00002907 Repair Chimney*
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name( t) (Fir (M)
Department Use Only
Project No.
2 Project Address (Not Mailing ddress) Space Zip
/D 9/0 e. ,�°2" ,�'�...- e2,a ..
3 City/Community
State
Subdivi Ion/Plat Name
Cir€eyes
4 Assessor ParceleQ*5' ei Be
Lot
Bicck -
Q6 7
16 Contractor Irm Name 66,4ed
ifije���` �,
Address„S7017
Zip
7
992
Cit -- —
State _ --eet
Phone
18 Contact Person
License No.
Phone different than above/-
�T-'
8 Owner/Agent (if different than 41 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work:
New ❑ Addition/Alteration ❑ Replace/Repair
10 Applicant Name )
17616/....1A..251.71"......
Street Address
O9, -
11&
Zip qqz'
/
CItY�!'v .�
State �%-
Phone /7Z-7 --40/?",t)--
%",t)--8
8VENT: Fan(s):
EvapCooler(s):
Hood(s):
Duct(a)1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
I Range s):
Gas Log(s):
Wood Stove/
Solid Fuel:
Gas Water Heater (8):
—
11 UNIT HEATER(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: Less than 3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU:
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas 0 ; Oil 0 ; Coal 0 ; Wood ITT— Solar 0
19 TYPEt919FRIBUTION: - 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
bdedQ APPLICATION l a
DATE 1