1984, 08-15 Permit App: 00001873 ACMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name - (Last) (First) (M)
Department Use Only / r'-
'
,!
/� [rµ 'r ` °✓', , i
Project No.
2, Project Address (Not Mailing Address) Space Zip
✓ 4Zel.-. / Y s 1.-zi/r�
3 City/Community
,S' 3->,i .">A; �:: y
State
SubdIviai /Plat Name
Ct 4t`c( Ive kki
4 Assessor Parcel No.
of 1 e, w q
Lot
Block
16 Contractor Firm Name
x .., ✓t
1 Street Address
r.. Ll7.G'
17 Zip
City
.f- As .
State
1. %4:
Phone _
•( .s =/7C,/
16 Contact Person /1//
License No.
Phone If different than above
8 Owner/Agent (If different than #1 above)
Business
Address
9 -Zip j City I State
Phcne
15 Describe Work: /- A. y»,,, .„1,,,..e._e.... -i s / %- f'/4'r
New NK Addition/Alteration 0
Replace/Repair ❑
10 Applicant Name
Street
Address
11 Zlp
City
State
Phone
( )
8 VENT: Fan(s):
Evap Cooler(s):
Hood(s):
Duct(s) 1:
Miscellaneous:
10 APPLIANCE:
Dryer(s): I
Range s):
Gas Log(s):
Wood Stove/
Solid Fuel:
Gas WaterHeater(s):
11 UNIT HEATER(S): Wall Mount: Y N
Floor; Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M: ' , ' -r '
,,r.... /,c;— :--
100-500M: ..
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. t.):
15 COMPRESSOR/HP: Less than 3::
3-15:
15-30:
30-50:
50+;
17 HEATING SYSTEM: 1-100,000 BTU:
100,001 +BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas ❑ 011 0 ; Coal 0 ;ypG Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air j Radiant 0 ; Heat Pump0
1* Number of separate zones for any heating, A/C or air handling system.
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
vitiate or cancel the provisions of any state of local laws regulating construction or the performance of
construction.
SIGNATURE OF-/
OWNER OR
APPLICATION -
DATE