1984, 07-25 Permit App: 00001434 Furnace7.4
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name t)) (First) ( (M)
Department Use Only
(hrlL �W 014- ¢ i
Project No. / 3Y
2 Project Address (Not Mailing Address) Space ip
3 City/Community i i
6 KA lug-
State
C3A-
Subdivision/Plat Name
4 Assessor cel No.
Lot
Block
Contractor Firm Nape
fiK12S•10 AGtlied- )J iwe .L a
-t`rorvc.v�
Street dress� _c
_ c-.42.30 � ,JJt opo
17 Zip
qg 2-0-1--
Cit
ip a tu(t�
State
L.)14-
Phone
( ) 535-- ?333
18 Contact Perso
License No.
---------3r
o
Phone if different than above
8 Owner/Agent (if different than 01 above)
nE ns6
2.08i. !
Business
Address
g Zip 1 City
State
I Phone
I`
15 Describe Work:
New ❑ Addition/Alteration
❑
Replace/Repair ❑
10 Applicant Name
( Street
Address
11 Zip
City
t State
i Phone(
8 VENT: Fan(s):
Evap Cooler (s):
Hood(s):
Duct(s)1: `_ Jv
Miscellaneous: 4, 4. —fia
AI a Cage ,�.
10 APPLIANCE:
Dryer(s): 1
Range s):
Gas Log(s):
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: 10,000 CFM or Tess:
More than 10,000 CFM: 7 :
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. t.):
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 b. k ra. NQ
r
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric Gas ❑ ; 011 0 ; Coal 0 ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Alr 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 the provisions of any state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR
DATE APPLICATION
(tc/gLi