1986, 12-07 Permit App: 00014449 Gas PipingMECHANICAL 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 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 �^`C APPLICATION
OWNER OR / -� DATE Z"-"% `��
Project # / I _/ q
7
Owner's Name Last First MI
m"lil y JJ� /47
Project Address (Street Name & Nurhber)
e. 03 L, .brs
City
S/a
State
Lv/7 "S /`t
ubdivision/Plat Name y�
2�%i.e. r0 /f'(/G`
Assessors Parcel #
Lot
Block
Plat #
Applicant 6:.-
j ry` 6.
Address
City
State
Zip
Phone
Business Phone
Contractor w
4-
S4`
Address
City
State
Zip
Phone
Contact
License #
Business Phone
Describe Work 6.,65 Pi Pyt..
Fans
Evaporative Cooler
Hoods
Electric Furnace/ Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
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
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5Outlets
6+ Outlets
Gas Fired Heating System
1-100, BTU
1(1,,,;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 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 �^`C APPLICATION
OWNER OR / -� DATE Z"-"% `��