1984, 09-25 Permit App: 00002568 Heat Pump1–
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name i(First) (M) Department Use Only
\ (,L-ast)n�
� � �Ap ^
l� pw.IL \'.Ld1�0_, Project No.
2 Project Address ( of Mailing Address Space Zip
1/
/16a...-0.....- 29 a–a G
3 City/Community
State
(-,C) qt.—.
Subdivislo /Plat Name
OPT Woed i0 Hrs
4 Assessor Parcel A
085/3 44/0
Lot
1 Block
I 2�/ '
16 Contracty�Flrm Name
V�A6i,,A e l
Strain r
II
17 Zip
29a"Sa(....jc1.l
City
StatejAX–
State
Phone
one
( )
Phone If different than above
18 Contact Person
License No.
Ai-1EWvr
.1.4.5 Ai
8 Owner/Agent (it different than M t above)
B ess Address "'
9 Zip
y^ ,q
Cit
State
Phone
15 Describe Work: v
New ❑ Addltion/A
teration / Replace/Repair 0
10 Applicant Name
Q
Street Address
11 Zip
City
State
Phone
1 )
8 VENT: Fan(s):
Evap Cooler(s): i
Hood (s):
Ducts) 1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
1 Range s):
Gas Log(s):
Wood Stove/
Solid Fuel:
Gas Water Heater(s):
11 UNITHEATER(S): Wall Mount: Y N
Floor:
V N
Suspended• Y N
12 AIR HANDLING: 10,000CFM or less'
More than 10,000CFM:
13 REFRIG SYSTEM BTU: 1-100M d- t1/QOO /F7
l�+Other:
100-500M:
500-1000M:
14 1000-1750M .J
Pressure Vessel (cu. t.):
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 0 ; 011 0 ; Coal 0 ; Wood 0 , Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; Heat Pura,
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
OWNER OR
APPLICATION Ay
DATE
•
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