1984, 12-18 Permit App: 00003759 Elec FurnaceI
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1
Owner's Name /fast)
(First)
(M)
Department Use Only
r
Project No.
2
Project Address (Not Mailing Address)
Space Zip
D L�'�-C�-'
3
City/Community
State
Subdivision/Plat Name
4
Assessor arcel No.
Lot Block
/
16
Contractor Firm Name
Str ddress
-�'�
17
17
Zi Cit y
State
Phone
C
Phone If different than above
18 Contact Person
License No.
AWE -I1 *225W
8
Owner/A (If different t ff1 above)
Bupipss Addre
9
Zip q ity
State
` Phone
15
Describe Work:
New
Addition/Alteration
❑ Replace/Repair ❑
10
Applicant Name
Street Address
C1 -d
11
Zip
City
State
Phone
1.
8
VENT: Fan (s):
EvapCooler(s):
Hood (s):
Duct($)1.
Miscellaneous: '
10
APPLIANCE:
Wood Stove/
Dryer(s):
Range(s): Gas
Log (a):
Solid Fuel:
Gas Water Heater (s):
11
I
UNIT HEATER(S): Wall Mount: Y N
Floor: Y
N
Suspended: Y N
12
I
AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
I 13
REFRIG SYSTEM BTU: 1-100M: �J ��
�P
700-500m:
500-1000M:
14
1000-175OM:
Other:
Pressure Vessel (cu. ft.):
15
COMPRESSOR/HP: Less than 3:
3-15:
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 Gas
❑ ; Oil ❑ ;
Coal ❑ ; Wood ❑ ; Solar ❑
19
TYPE DISTRIBUTION: Forced Air ❑
Radiant ❑
Heat Pump
1" Number of separate zones for any heating, A/C or air handling system. ,;Le o
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 OFAPPLICATION ILL
OWNER OR Cis-- ,DATE 1°2
�``�
10
1
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3CA L -r= e�,N\A
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