1986, 08-26 Permit app: 00012880 Gas PipingMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE 'RENT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Acaz;
3/5ri7
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 corn -
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 1 �� Z,� 4/ APPLICATION /la?4-f&
OWNER OR `l/ O/
Project# ,I82)
Owner's Name Last First MI
/C4/4e L9—/he PA, 7 -
Project Address (Street Name & Number)
_5/0/ 0NG1'
City State
14
Subdivision/ Plat Name
Assessors Parcel # 0 OSF•�C ^5 ^1 1)
Lot
BlockIL
Plat #
Applicant
Address
City
State
Zip
1
Phone
Business Phone
Cont
0 actor� 60 �/ ? 4' A- / C
cles
� .5-J-2 ��d2/.
City
t Sega 1(04
StateZip
4
974 I a
Phone
J y97.5"
Contact ,l /License
7 /C 8 '41° _
#
2a3do /thee: A_ /70-82-
Business Phone
y 4797.5
Describe Work %!‘d
Fans
Evaporative Cool
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel /Wood Stove
Air Handling Units
l
0-10,0130 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
'1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
,
Gas Fired Heating System
1-100,000BTU
10,,,:.00+BTU
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 corn -
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 1 �� Z,� 4/ APPLICATION /la?4-f&
OWNER OR `l/ O/