1985, 05-15 Permit App: 00004458 Mechanical Fixtures L 7) 55 — ff o \ bU;LDING & SAFETY
MECHANICAL PERMIT APPLICATION WORKSHEET
• PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project#
Owner's Name G u7frstMI
Project Address(Street Na�Num
/ 4/22 -fir A v k
City 14-State _/J Subdivision/ lat Name / S J
N_3 44 `1 1 0 Lot Block Plat M
Ass 1111
Aptic 6-g t54,/ Ar /plicant Address f/3
Pc
City State Zip Phone
Business Phone
Contractors ,y Address
.4 t'
City State Zip Phone
Contact License# Business Phone
•
Describe Work
Fans Evaporative Cooler Hoods Electric Furnace/Ducts Miscellaneous
Dryer Range Gas Log Gas Water Htr. Solid Fuel/Wood Stove
I
Air Handling Units 0-10,000 CFM 10,000+CFM
Refrigeration Systems/ 1-100M 101-500M 501-1,000M
Heat Pumps(BTU)
1,001-1750M Over 1750M
Compressor 0-31-IP 3-15HP 15-30HP 30-50HP 50+HP
O ' c ' 1-5 Outlets 6+Outlets
Gas Pipine O
Gas Fired Heating System /
/�e.1-100,000BTU 10.,Z.00+BTU
ifis -47'5x;?---
// e
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 ofd permit does not presume to give authority to
violate or cancel the prgvisions of any state of local ,1w 'is,,regulating construction or the performance of
construction.
0/1 '' V- 1'.--SIGNATURE OF , �/i; . �, TION -�
OWNER OR �CJ ' 1 DATE. 11 �