1987, 06-18 Permit App: 87001873 Furnace, ACMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
�3om�4�S
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 120
OWNER OR
APPLICATION / f e /8 2
DATE �P
Project # /6-0
Owner's Name LastFirst MI
V14.11--% . GQ-Jrm
Project Address (Street Name & Number)
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State
Su ion/Pllat Name 0p C
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rs rcel #
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Block
Plat #
Applicant
Add
ess
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City
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State
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Zip
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Phone
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Business Phone
Contractor
Address
City
State
Zip
Phone
act ParAlet->ty‘,`
Lice_ sfe
loess Phoneyvvpi r
Describe ork
(A.
Fans
Evaporativ oler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Hfie
Solid Fuel/Wood Stove
Air Handling Units
0-10,000 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP n
/
3-15HP
15-30HP
30 50HP
50+HP
Gas Piping
1-5 Outlet
6+ Outlets
Gas Fired Heating System
1-100,000BTU 9 0.€
10AAt �.,:,W+BTU
W
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 120
OWNER OR
APPLICATION / f e /8 2
DATE �P