1984, 09-28 Permit App: 00002552 FurnaceMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1
_
Owner's Name (Last) ____LFirst)
r7 YL!,_ � (U
(M)
I Department Use Only
Project No.
2
ProjectAddress(Not Mailing Address)
1 v
Space
Zip
J
3
_
City/Community
state
Wi
Subdivision/ Plat Name
4
Assesso Parcel No.
!� 5-13 — o spa
Lot
Block
16
Contractor Firm Name
Street Address
17
Zip
City
State
Phone
18
Contact Person
License No.
Phone if different than above
8
Owner/Agent (if different than N1 above)
Business Address
9
Zip
City
State
phone
15
Describe Work:
New 1 1
Addition/Alteration ❑ Replace/Repair
10
Applicant Name
Street Address
11
Zip
City
State
Phone
8
VENT: Fan(s):
Evap Cooler(s):
Hood(s):
Duct (s) 1:
Miscellaneous:
10
APPLIANCE:
Dryer(s):
Range(s):Gas
Log (s):
I
Wood Stovel
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
REFRIG SYSTEM BTU: 1-100M:
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 ❑ Oil
❑
Coal ❑ Wood F-1 Solar ❑
19
TYPE DISTRIBUTION: Forced Air C ;
Radiant ❑
Heat Pump
1* Number of separate zones for any heating, AIC 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