1985, 10-11 Permit App: 00008341 Heat PumpMECHANICAL 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
OWNER OR
APPLICATION �--�
/
DATE
Project N Si
Owner's Name t t MI
D (.ci//N4- a 10
Project Address (Street Name & Number) 1
</-i t
Cit "
c.
State
bij A
Subdivision/Plat Name
s Parcel#
(2/0)
Lot
Block
Plat #
ApplicaSI
Address
City
State
Zip
Phone
Business Phone
Con rector _
l____
0
Address
e �
St a
74
Zip
q /
`
Phone
'.1r 2/o e
Con : / I
I e Ii A.
License #
AMP f
Business Phone
Describe Work
` -4
�%-t`
l,04,.` U
Fans
Evaporative Cooler
Hoods /
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
i
Solid Fuel /Wood Stove
Air Handling Units ��' 0
0-10,000CFM
10,000+ CFM
Refrigeration Systems/ V
Heat Pumps (BTU)
}�1 ��� �e4-101-500M
S !1
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
.10%,,,300+BTU
Gas Fired Heating System
1-100,000BTU
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 �--�
/
DATE