1985, 06-13 Permit App: 00005910 AC 1 �
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name, / (Last) (First) (M) Department U e Only
Al
/
Alt
/E" y �t Project No. I C/
2 Project dress(Not railing Address) Space Zip
° /17 Pc4/._Aci q9
3 City/Community State Subdivision/Plat Name
5/674-%/r4 a)4S
4 Assessor Parcel No. Lot Block
16 Contractor Firm Name , Street Address
A)()A&)c) /,L4-4 7'/ — A- r`/w' r ! /:', ', C�/%� /11�
17 Zip City State Phone
9-7,2 ke//.s/• (J-07) 67:3 2-7— /7
18 Contact Person c'f11 License No. Phone if different than above
(.??167.5'6f e5', I; -711 CCJ/(-7,q) ;,--).3z);) /f/r'h706,AM-re /?z-
8 Owner/Agent(if different than#1 above) Business Address
g Zip City State Phone
( )
15 Describe Work:
New Addition/Alteration ❑ Replace/Repair 0
10 Applicant Name Street Address
11 Zip City State Phone
( )
* *
8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: Miscellaneous:
10 APPLIANCE: Wood Stove/
Dryer(s): Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
Z 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
2
a 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
5
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
tl
0
14 1000-1750M: Other: Pressure Vessel(cu.ft.):
a
>I—
O 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
Q
W 16 GAS PIPING SYSTEM:Number of outlets:
m
2
Z 17 HEATING SYSTEM:1-100,000 BTU: 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas 0 ; 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.
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 1 ` APPLICATION
OWNER OR � j / DATE