1984, 10-23 Permit App: 00002970 Gas Piping1—
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name i , ej S \<First) f A,� � 1
�. F 1V \1 �
P Use Only
oject No.
Project No.
2 Project Address (Not Mailing\6eD 1 0je\ Space Zip
03 9'to L
3 City Com`"�oynyity
State
Subdivision/Plat
Name
4 Assessor arcel No.
Til Sif 3-- / CZ 5
LotBlock
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16 Contractor Firm Name
Street Address
17 Zip
City
State
Phone
( )
18 Contact Person
License No.
Phone If different than above
8 Owner/Agent (if different than #1 above)
Business Address
9 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):
EvapCooler(s):
Hood(s):
Duct(s)1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
I Range s):
Gas Log(s):
Wood Stove/
Solid Fuel:
Gas Water Heater(s):
11 UNITHEATER(S): Wall Mount: Y N
Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. 1):
15 COMPRESSOR/HP: Less than 3:
3-15:
15-30:
30-50:
50+:
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16 GAS PIPING SYSTEM: Number of outlets:Oc �) k k Cn aT 1
�
17 HEATING SYSTEM: 1-100,000 BTU: S S 1 6 D Q
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric 0 ; Gas 0 ; 011 0 ; Coal ❑ ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; 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 APPLICATIONN �a3_y 1 .�
OWNER OR \4ij& �`� ` `�