1984, 11-07 Permit App: 00003257 FurnaceZ
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name(Las) (First) (M)
Department Use Only
. II
M � 'n e.s v ` -o W
Project Na
2 Project Address 1 of Mailing Address) �(�(� _
cd a'A U (c Ik.Oh10.\�
D Zip
RA.)
t` A.)
3 City/Comty\\{
State
Subdivision l Plat Name
4 As�sor�o,p
6 X °C
Lot
Block
16 Contract Fi rm Name
\l kilA CtC--,\N 1 Y�P rilL tC
Street Address/rre_
E 4l 1�� � 7 1� tv`oi
17 Zip
Rct
o3
City
�N
State
V.)o.,.
Phone
X638) li5a3
18 Contact Person
risi
License No.��
GNG�,\A
--11
ci vi
Phone it different than above
8 Owner/Agent (if different than NI above)
SfiH JL -
Business
Address
9 Zip _
City
State
Phone
I )
15 Describe Work: C`'w � IA
� JO13 �, —
Addition/Alteration
GG C30.%
❑
\\\��,
Replace/Repair @X
`
10 Applicant Name
Street
Address `
11 Zip
City
State
Phone
( )
8 VENT. Fan(s):
Evap Coolerla)'
Hoods)
Duct(s) 1'
Miscellaneous.
10 APPLIANCE'
Dryer(s): (Ranges)'
Gas Log (e):
Wood Stove(
Solid Fuel.
Gas Water Heater(s):
11 UNIT HEATER(S): Wall Mount: Y N
Floor.
Y N
Suspended. Y N
12 AIR HANDLING' 10,000CFM or less:
More than 10,000 CFM
13 REFRIG SYSTEM BTU' 1-100M.
100-500M.
500-1000M'
14 1000-1750M:
Other:
Pressure Vessel (cu. CI'
15 COMPRESSOR/ HP: Less than 3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU: i—
'OO ��f�
1
100,001+ BTU.
18 TYPE FUEL SOURCE: Electric 0 Gas A.; Oil 0 ; Coal ❑ ; Wood 0 ; Solar 0
/ \
19 TYPE DISTRIBUTION' Forced Air 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 the provisions of any state of local laws regulating construction or the performance of
construction.
SIGNATURE 0
OWNER OR
r4:411 p + DATE CATION
117 gig