1984, 12-21 Permit App: 00003783 Gas Logr
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MECHANICAL PERMIT APPLfCATON WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1
Owner's Name (Last)
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Fir t) (M)
Department Use Only
Project No.
2
Project Addreessss (Not Mailing Address) Space Zipp
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3
City/Community
Stattee��
Subdivision/Plat Name /
4
Assessor Parcel No.
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Lot
Block
16 Contractor Firm Name�
Street Address
17
Zip
City �(f
State
Phone
/ 7
18 Contact Person
Licensee No.
Ily
Phone If different than above
8
Owner/Agent (if different than 81 above)
Business Address
g
Zip
City
State
Phone
15
nbe Work:/IlwG / � /►
m Q � New ❑
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Addition/Alteration >I� Replace/Repair ❑
10
Applicant Name
Street Address
11 Zip
City
717
Phone
( )
1
8
VENT: Fan(,):
Evap Cooler(s):
Hood (a):
Duct(s)1:
Miscellaneous:
10
APPLIANCE:
Dryer(s):
Range(s):
Gas Log (a):
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:
100-50OM:
500-1000M:
14
1000-175OM:
Other:
Pressure Vessel (cu. ft.):
15
COMPRESSOR/HP: Less than 3:
315:
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 ❑
Oil ❑ Coal ❑ ; Wood ❑ Solar ❑
LEEISTRIBUTION:
Forced Air ❑
Radiant ❑ 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 APPLICATION/;,
OWNER OR DATE