1986, 12-10 Permit App: 00014478 Piping1
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE 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
OWNER OR
%kP•C.._.
APPLICATION
DATE
Project 0 I Lig.le
Owner's Name
Ale) ` Lr t First MI
„cl VA/eTh L. / a Yof
Project Address (Street Name & Number
E 9S2.0 1vo� 'lue
City/�
State
Subdivisi nl P t Name r _ /
tit -
Assessors Parcel 0 0 A 3 0 ct r cf
r y/
Lot
5
Block
Plat 0
Appllcan
�o/✓Nei-14 (4 dke (
Add ess
S 9 C Z U /1/ co K 11
City
raa<
State
I .)61
Zip
9 99Lca(t)
Phone
9 a 4 3 afr,
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
License 0
Business Phone
Describe Work
Fans
EvaporativeCooler
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
101-500M
501-1,000M
1,001-1750M
Over1750M
Compressor
0-3HP
3-15HP
15-SOHP
30-50HP
50+HP
Gas Piping
1-5 Outlets %
t/
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10v,J00+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
%kP•C.._.
APPLICATION
DATE