1986, 07-11 Permit App: 00012120 Heat Pump•
H
Z
W
2
a
5
0
LL
>
O
0
H
C
z
W
m
i
z
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) l (First) (M)
1L l�—ti
Department Use Only �y
Project No. ! iJ
/
2 Project Addres of Mailing Address) Space Zip
5 / L /' L —Q.- L- -J'Ft,
3 City/Communit
State
Subdivision/Plat Name
4 Assessor Parcel N
Lot
ll I Block
16 Contractor Firm Name
Str:- • ddress
- - I 7/ —1t-
�.c�-ems-
17 Zip 1
/ JC (
City
�.._'�!`r-tom _
State
C Cj---
Phone p
( ) Com` rT (J S
18 Contact Person
License No.
Phone if different than above
8 Owner/Ag t (if different than #1 above)Bus�Address
t •I•:"--
[
co =_e:1_,ys-
9 Zip
97' V
City
State
(cL_.
Phone
(
15DescribeWork:
New Addition/Alteration
0
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:
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 N
Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M: a, CC
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. t.):
15 COMPRESSOR/HP: Less than 3:
3-15:
15-30:
( 30-50: 150+:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU:
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric 0 ; Gas 0 ; 011 0 ; Coal 0 ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; Heat Pu
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. ALUM
A DIVISi-
SIGNATURE OF
APPLICATION
OWNER OR PCEaV.42r, DATE
92E,3257