1986, 05-21 Permit App: 00011199 Mechanical FixturesM,ECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT A,ND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) C j (First) (M)
Department Use Only
Protect No.
2 Project Add resg (Not Mailing Address) Space Zip
1
3 City/Community
State
on/ Plat Name
4 Assessor Parcel o.
Lot
Block
16 Contractor Firm Name
Stree`Address
1\
17 Zip 7T
City
State
Phone
—
18 Contact Person License No. _ Phone if different than above
8 Owner/Agent f different than #1. above) I Business Address I
9 Zip
City
State
Phone
15 Describe Work:
New Addition/Alteration ❑ Replace/Repair
10 Applicant Name
Street Address
it Zip
City
State
Phone
8 VENT: Fan(s):
EvapCooler(s):
Hood (s):
Duct(s)1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
Range(s):
Wood Stove
Gas
Log (s):
Solid Fuel:
Gas Water Heater(s): n0 C>
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:
100-50OM:
500-1000M:
14 1000-175OM:
Other:
Pressure Vessel (cu. ft.):
15 COMPRESSOR/HP: Less than 3:
3-15:
15-30:
30
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU:
100,001 +BTU:
18 TYPE FUEL SOURCE: Electric ❑ Gas ; L{ ; Oil ❑ Coal ❑ Wood ❑ Solar ❑
19 TYPE DISTRIBUTION: Forced Air Radiant ❑ Heat Pump .7
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
APPLICATION c -
DATE 0t
G(—