1984, 08-31 Permit App: 00002104 Furnace*
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last)First)d (M)
JPill 5-4' Aei.srem,
Department Use Only Anal"-
Project No.
2 Project Address (Not Mailing Address) Space Zip
7z -AV Azo e/x---77"4-
3 City/Community
�-epv6 -A e._
State
4/4"-
Subd v ion/ Plat Name
6Er/es 46 "Tr
4 Assessor Parcel No.
`_
/25Si— loS ?
Lot
I
1
Block
/�
_
16 Contractor Firm NameO e� _ 62
7457r re°
Street ddress S7
17 ZipIVO(
'+•
I City ���
State �e
Phone ) 7
18 Contact Person
License No.
*z3DZ1
,.).s41:-'.�
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business
Address
9 Zip
City
State
Phone
_ ( )
15 Describe Work:
New 0 Addition/Alteration
0
Replace/Repair
iName
10 Applicant
YNa%' L 01-5
Street
Address
11 Zip
City
State
Phone
( )
8 VENT: Fan(s):
Evap Cooler(s):
Hood(s):
Duct(s) 1
Miscellaneous:
10 APPLIANCE:
Dryer(s): 1
I
Range s):
Gas Log(s):
Wood Stove/
Solid Fuel:
Gas Water Heater(s):
11 UNIT HEATER(S): Wail Mount: Y N
Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. t.):
15 COMPRESSOR/HP: Less than 3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Number of outlets: !4
17 HEATING SYSTEM: 1-100,000 BTU: */)7
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric 0 ; Gas • Oil 0 ; Coal 0 ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; 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 th- • • Is of any state of local laws regulating construction or the performance of
construction.
1
roar
SIGNATURE
OWNER OR
APPLICATION e
DATE