1985, 03-20 Permit App: 00004633 AC-`` MECHANICAL PERMIT APPLICATION WORKSHEET "i
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1
Owner's Name (Last)
�-le-Ay
(First) (M) Department Use Only
Project No.
2
Project Address (Not Mailing Address)
Space Zip
3
City/Community
State
Subdiv'sio /Plat Name
C(JAJ 14AI V d 6-f `
4
Assessor Parcel No.Lot
'' -1.1,7tf
Block
16
Contractor Firm Name �,
Street Address '7
17
Zip
7-0
City
State
Phone
18 Contact Person
UX�C u� t/ ri h�
License No. P
- 6 --- - �a21v
Phone if different than above
8
Owner/Agent (if different than N1 above)
Business Address
9
Zip
City
State
Phone
15
Describe Work:
New ❑
Addition/Alteration ❑ Replace/Repair
10
Applicant Name
Street Address
11
Zip 0
City
State
Phone
8
VENT: Fan (s):
TEvapCooler(s):
Hood(s):
Duct(s)1:
Miscellaneous:Q,(„�j
I/ ti
10
APPLIANCE:
Dryer (s):
Range(s): Gas
Log is):
Wood Stove/
Solid Fuel:
Gas Water Heater (s):
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
rlPl�
REFRIG SYSTEM BTU: 1-100M: a,/
Y
100-50OM:
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
Cy; Oil ❑ Coal ❑ Wood ❑ Solar ❑
7`
19
TYPE DISTRIBUTION: Forced Air ❑ ;
Radiant ❑ 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 APPLICATION
OWNER OR DATE��
AL-
SIGNATURE
L