1984, 11-07 Permit App: 00003267 Mechanical Fixture •
MECHANICAL PERMIT APPLICATION WORKSHEET
-9° PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name ( (First) (M) Department Use Only
�� /....X. Project No.
2 Project Address(Not M ing Addr Space Zip
/7// /
3 City/CommunityState Subdivision/Plat Name
42�2e
4 Assess&Parcel No. Lot Block
16 Co ctor FZ ' i
ame Street Address
//1c < /793 7c7;w7c/s
1 ip City State Phone
qyge, ( ) 9,
18 Contact Person License No. Phone if different than above
WWI
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work:
New Addition/Alteration ❑ Replace/Repair ❑
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
W
a 12 AIR HANDLING: 10,000 CFM or less: „�d a More than 10,000 CFM:
o
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
LL
0
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
a
>-
I—
O 15 COMPRESSOR/HP: Less than 3: 3-15: 15-30: 30-50: 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets:
m
Z 17 HEATING SYSTEM:1-100,000 BTU: 02 t9 /44.'a) 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric fy; Gas ❑ ; Oil ❑ ; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air Ly Radiant ❑ ; Heat Pump E0
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 .earl laws regulating construction or the performance of
construction.
SIGNATURE OF - ..>a /�' ►� / APPLICATION
OWNER OR / —.0"/-- -1,T"..:� Am.... ----- DATE /7 1"/