1984, 09-25 Permit App: 00002561 Heat Exchanger*
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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)
Wks - 5mt7t,( / omc $
Department Use Only
Project No.
2 Project Address (Not Mailing Address) tI,+ Space Zip
3 City/Community
Stat
Subdivision/ Plat Name
4 Assessor Parcel No.
LotBlock
2561
Contractor Fr Name
50n► At ii- a� %t iw3 j 10r2 ei.),vdr 1/0w r �S
Street Address
E--- -12-3 0 MSS •/6/4)
17 Zip
q4z--
Cit •
State
W,-
Phone
( ) 535`.2333
18 Contact Perso
License No.
�j 16 k
Phone If different than above
8 Owner/Agent (If different than M1 above)
Business
Address
g Zip
City
State
Phone
( )
15 Describe Work:
New ❑ Addition/Alteration
❑
Replace/Repair 0
10 Applicant Name
Street
Address
11 Zip
City
State
Phone
( )
8 VENT: Fan(s):
Evap Cooler (s):
Hood(s):
Duct(s)1: 1/
Miscellaneous:
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
Floor:FlY N
Suspended: Y N
/1N n %
12 AIR HANDLING: 10,000 CFM or less: Af R� 2 �T��7
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: Less than 3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU:
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric Gas ❑ ; 011 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 the provisions of any state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR
APPLICATION
DATE
q ias-161