1984, 06-05 Permit App: 00000670 Furnace . a. -
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M) Department Use(2gti
_2 Project Addres; t- Project No. Cot Address)Mail' Space Zip
/5l? -d 4 C t -a-- O�X� ' ""7-1-110,-
3
` t 113 City/Commun' I StateSubdivis' n/PlatName ,/
t I�°ban& H///S Is/'
4 Assessor Parcel 'o. Lot Block
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16 Contractor Firm NameAddress
Syr
cC9-1-44—A. 4 S.J._ t-- I S1 . 7,3//
17 ZipCity State Phone
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18 Contac*mon 'License No. Phone if different than above
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8 Own . Agent(if different than 1 above) Busin s Address
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9 Zip City State Phone
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(„S.0 ) 701-Y-3 S<t.
15 Describe Work:
New X. Addition/Alteration ❑ Replace/Repair Li
10 Applicant Name Str ddress _
Ga-(-�.�." �,s.,.,C - f3// -
11 Zip City State Phone
4
8 VENT: Fan(s): EvapCooler(s): Hood(s): Duct(s)1: X .: Miscellaneous:
10 APPLIANCE: Wood Stove/
Dryer(s): I Range(s): Gas Log(8): Solid Fuel: Gas Water Heater(s):
Z 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
W
a 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
of13 REFRIGSYSTEM BTU: 1-100M: '4•00t537lA. 100-500M: 500-1000M:
(*4 c* /
1e 1000-1750M: Other:
Pressure Vessel(cu.ft.):
71%6
15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets:
CO
2
Z 17 HEATING SYSTEM:1-100,000 BTU: ' /p 01..co c, er 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric X;� Gas ❑ ; Oil ❑ ; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant ❑ ; Heat PumK
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 APPLICATION
OWNER OR c2..,„vr` - --+:1.-3--...i-e-v,,. ���t�e� DATE l —3- -oF-X