1984, 10-15 Permit App: 00003015 Furnace, Heat Pump*
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Nam ,(Last) (First) (M) Department Use Only
� / '41 ( / �7r(,J Project No.
2 Project Address (No Mailing Address) ( Space Zip
R0 < t 3 MCL').11 Pe /24-----
3 City/ mmunity
0 e
State Subdivision Plat Name
WA- 1* ate 14/14Tr
4 As r Parcel No.
/551N-�l&e58
Lot Block
8_i2
30/5
16 Co ra�cCtor F'rm Na% %
U' CI i/ L l
�`/� J Street Address ' r /A
l ( 1 " lL(7/ 6 /V .I% l/4 lf/1'1
171; C
Cit ,/Phone
State
18 Cont:. t P •n c
yAm
License No.
Phone if different t+ian above
8 Owner/Agent (if different than #1 above)
Business
Address
9 Zip
City
State
Phone
( )
15 Describe Work:r ;12AtC�'
New O Addition/Al.
(, —4...
ion ❑ (`
Replace/Repair
10 Applicant me /1/0
� /} , J �q _ p 6
t°J�/ r f -- cC'4 '*--
Street
Address
11 Zip
City
State
Phone
) gZ 7 7/0
8 VENT: Fan(s):
Evap Cooler(s):
Hood(s):
Du (s)1: 160
Miscellaneous:
10 APPLIANCE:
Dryer(s):
I Range s):
Gas Log(s):
Wood Stove/
Gas Water Heater(s):
Solid Fuel:
11 UNIT HEATER(S): Wall 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. 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:
t
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric )I+; Gas 0 ; 011 0 ; Coal ❑ ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air ,X; Radiant 0 ; Heat Pump
1* Number of separate zones for any heating, A/C or air handling system.
26.50
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) n —
DATE ` l!