1985, 02-27 Permit App: 00004375 Furnace, Water HeaterMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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 colt
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 a 7 5,
OWNER OR �� DATE
Pre4e,1 # , 3.-7 5
Owner's Name Last First MI
Al c CIA ATI4 Y►1► g_p-
Project Address (Street Name & Number)
5. 3 (. 0 Ci Lc) Q.-e,T'T 4 _
City
State
Subdivision/ Plat Name
Assessors Parcel #
Lot
Block
Plat #
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor
3 WN ,T14 N-ex,,A..;.,,s,,
Address
E - ion ivc)(RA
City
5p
State
w A
Zip
9,..2o 7
Phone
Contact
License #
/J •2 c - Sn/S
Business Phone
30 8—yy3
Describe Work
Fans
Evaporative Cooler
S
Hoods
Electric Furnace/ Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas 1N'r Htr
�t/010,000+
Solid Fuel /Wood Stove
Air Handling Units
0-10,000 CFM
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
1-5Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU iv ,�0
c(? • �i
10v0;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 colt
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 a 7 5,
OWNER OR �� DATE