1985, 03-18 Permit App: 00004548 Mechanical Fixture -'C S
F MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name ( st) (Fir (M) Department UseJyTQ�nl
/� �' /ins' Project No. f
2 Project Address(Not Mailing Address) Space lip
5 . ...• r/4 dbe
3 City/Communityy� State Subdivision/Plat Name
(z,<,,, z.y i,/./4-
Lot Block
4 ssess Parcel No.
16 Contracto irm Name , ..� Street Address
/ /' 0°,S!r't-it.�11Z C / 7r -a3 ., fi^///7C'/S
17 Zi ity State Phone
9 9A:. 'U 7 4 ::= /),‘0911 j4' ( ) 4/6(>94169‘;
18 Contact Person License No. Phone if different than above
_ 411 --_,;1" +► a.5...' -/ 6/ ' 0)
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 I Street Address
11 Zip City State Phone
( )
* *
8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: i Miscellaneous:
10 APPLIANCE: Wood Stove/
Dryer(s): Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
I— 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
Z
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a 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
7
0
13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
LL
0
d14 1000-1750M: Other: Pressure Vessel(cu.ft.):
>-
I-
0 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
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W 16 GAS PIPING SYSTEM:Number of outlets:
m
Z 17 HEATING SYSTEM:1-100,000 BTU: .' x 1.-1-1 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric Gas ❑ ; Oil ❑ ; Coal 0 ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air y; Radiant ❑ ; Heat Pump❑
1* Number of separate zones for any heating, AIC 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 •- laws regulating construction or the performance of
construction.
SIGNATURE OF - :' =e ', APPLICATION
OWNER OR _� i I DATE c.---/ e '_'€5.5
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