1985, 03-26 Permit App: 00004685 Furnace, Piping•
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MECHANICAL PERMIT APPLICATION WORKSHEET -Fo nb
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M) Department Use Only
CdoNr7iVa e, -y-/OA/ Project No.
2 Project Address (Not Mailing Ad ress) Space Zip
,86"a / .o/ferrA
3 Cit /Community
State
Subdivision/Plat Name
4 Assessor Parcel No.
Lot—_
� Block
I/40 ��
16 •ntractor Firm Name
'etas G_ �._ 1. .. _ _�' it � -1�.
Street Address
./P�__. , .,,s
-i
17 Zip /
-
_ /
Phone
18 . tact Person / /
11 �..-� OW -i .. E �. , .
License No.
— : / --
Phone if different than above
8 Owner/Agent (if different th above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work:
New 0 Addition/Alteration 0 Replace/Repair 0
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
8 VENT: Fan(s):
EvapCooler(s):
Hood(s):
Duct(s)1:
Miscellaneous:
10 APPLIANCE:I
Dryer(s): Range s}
Gas Log(s):
Wood Stove/
Solid Fuel:
Gas Water Heater(s):
11 UNITHEATER(S): Wali Mount: Y N
-Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or fess:
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: Lessthan3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Number of outlets: /-
17 HEATING SYSTEM: 1-100,000 BTU: 76_ 000
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric 0 ; Gas X; 011 0 ; Coal ❑ ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air ii(; 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
�,,, APPLICATION
/ice DATE