1986, 06-09 Permit App: 00011648 ACMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMkl=-TE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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/a;�
APPLICATION
OWNER OR DATE
Project /t /
Owner's e /I ast First
✓ C
MI
Project Address (Street Name & Num
City
State
Subdivision/ Plat Name
Assessors Parcel#
Lot
Block
Plat#
Applicant
Address
City
State Zip
Phone
Business Phone
Cit� 1
Stateto
Phone
Contc�ct
License � � 'q
�
in✓esa Phone
Describe ork c�
Fans
Evaporative Cooler
Hoods
Electric Furnace/ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/ Wood Stove
Air Handling Units
0-10,000CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1, 000#
1,001-1750M
Over 1750M
Compressor
0-3HP
v
3-15HP
15.30HP
30-50HP
50+HP
Gas Piping
1-50utlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10u,v00+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/a;�
APPLICATION
OWNER OR DATE