1986, 07-11 Permit App: 00012064 Gas PipingMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
t
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
t7WNER OR DATE
f _..
Project #
Owner's N me
Last
First MI -
Project Address (Street N e & Number) �+
All
City
State
Subdivi on/Plat Name
Assessors Parcel#
-
�
Lot
Block
Plat k
Applicant-
Address
City
State
Zip
Phone
\
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
License M
Business Phone
Describe Work
C
�70�
Sw ( M " nt G L"
Fans
Evaporative Cooler
Hoods
Electric Furnace/ Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/ Wood Stove
Air Handling Unita
0-10,000CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1 -loom
101-500M 75-07
-1,000M
1,001-1750M
Over 1750M
Compressor
7—p-
3-15HP
'7
15-30HP
30-50HP
50+HP
Gas Piping
1-5outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10.,:;0+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 APPLICATION
t7WNER OR DATE