1986, 07-17 Permit App: 00012198 ACi
MECHANICAL -PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
910)( /00 Aalat
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 77/ 7 /f e
Project p . / � i'r%Owner's
Name Last. - n F6/ MI
iiia
Project Address (Street Name & Number
L, ' 6 (, o S 7)/1)-4--'42-15-1A.
City Sista
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plate
Applicant
Address
City
State
Zip
Phone
Business Phone
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BusinessPhone
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Describe Work _
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Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/Wood Stove
Air Handling Units
0-10,000 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
2 3/ 000 � .
101-500M
501-1,000M
.G ✓
1,001-1750M1
Over1750M
Compressor
0 -31 -IP
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Healing System
1-100,000BTU
10v,300+BTU
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 77/ 7 /f e