1984, 08-22 Permit App: 00001986 FurnaceMECHANICAL PERMIT APPLiuJT!ON WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 p) nor s Name' = (Last) (First)
`, ��° .. IM)
- s
W
W
tl'
Department Use Only
s ,
I'�':'` 1 •J ,.. rf
Protect No.
2 Project Addrees (Not Mailing Address) Space Zip
9 f , J -. a99f E-'
—J
•3 City/Community
C
State
Subdivision/Plat Name
4 Assessor Parcel No
Lot 1
Block
,
16 Contractor Firm Name .
r , iso i' - f-.<<, / , . L. -
Street en
p. k '/ //
,,
17 Zip . l
/� }
,
City
State
Phone _
'7-//
18 Contact Person ,„; +, , . , I } i ;.>r• ",
yfJ S .fFPi%er
- =
License No.
, , 4 • /YA/7-
-8
Phone If different than above
8 Owner/Agent (if different than 01 above)-
Business
Address
Zip _
- 1
i
I
`is
.. -
i'flO+ib
( )
15 Describe Work: /4/ / �. ` `s''1..r% /n- 1, j.Y /S": L'' 4 ! _
New ❑'- Addition/Alteration 0
Replace/Repair 0
10 Applicant Name
Street
Address
11 Zip
City
State
Phone
( )
6 VENT: Fan(s): .'
Evap Cooler(s):
Noodle):
Ducts) 1:
I•
Miscellaneous:
10 APPLIANCE:
Dryer(s): Range a):
Gas Log (5):
Wood Stove/
Solid Fuel:
Gas Water Heater(a).
- 11 UN r HEATERS) WaJI Mount:. Y N : .
Floortn .Y. N
Suspended: Y N
12 Ain HANOL )NG:. 10,000 OF.M or iese s
More han 10,000 CFM:
13 REFRIG SYSTEM BTU ' 1-100M:
100-500M.:
500-1000M:
14 t i.%.Lt 7.,2M -'Other:
. _
Pressure Nasals) (cu. h.):
15 COMPRESSOR/HP Leas han 3:
..,:40,,,, •
3-15 '
15-30:;
30-50:
50+:
�� eW� 44/ria
s
17 HEATING SYSTEM' 1-100,00; BTU: -
_
100,001 + BTU:
18 : TYPE FUEL SOURCE: Electric C' ; Gas 1 : Oil C3" ; Coat ; Wood ❑ ; Solar 0
+8 TYPE DISTRIBUTION: Forced Air 1;7: ; Radiant 0 Heat Pump _
1* Number of separate zones for any heating, AIC or air handling system.
� a.
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�j-` Z �/
DATE •