1986, 11-03 Permit App: 00014015 FurnaceMECHANICAL 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 APPLICATION `/
OWNER OR - lie -r-- c/O'Ti DATE 3 ,e
Project #
MI
Owner's Name fast First,94 4
/r
.6b
Project Address (Street Name & Number)
S 3 6-06 !7l l/`Ssy
City//
State
Subdivision/ Plat Name
Parcel N
Asse5kW
Lot
Block
Plat #
Applicant
/e /2 /11,/9 r1
Address
_ A' 3-7 2-i C /W7.9 '
City `
5-", /tel1;1W
State /��j�
Wil /tel r
Zip j
4/ g �
Phone
Business Phone
'I — /Yo5—
Contractor
Address
City
State
Zip
Phone
ContactLicense
%7Ad17:7
#
%e, /t�A151 L/e
Business Phone
Describe Work
./15 -iii 491- litit970C
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/Wood Stove
Air Handling Units
0-10,000CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+HP
/'
Gas Piping 6//
1-5 Outlets 2
6+Outlets
7 ,p0
Gas Fired Heating System
1-100,000BTU /
100+BTU
VX - ate
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 APPLICATION `/
OWNER OR - lie -r-- c/O'Ti DATE 3 ,e