1984, 11-29 Permit App: 00003575 MechanicalMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND f '
1
2
Owner's Name (Last) (First)
/dma 12 e
Project Address (Not Mailing Address)ledSpace
��s . .� //4 r
(M) I Department Use Only
�Project No.
Zip
3
City/Community
State
Subdivision/ Plat Name
4
AssessoF Parcel No.
Lot
Block
16
Contractor Firm Name
Street Address
17
Zip
?20/
City
o9�'arl�,
State
Phone
18 Contact Person r
Ger a/- ,DOLvim,
License No.
Phone if different than above
8
Owner/Age t (if different than N1 above)
Business Address
9
Zip
City
State
Phone
15
Describe Work:
New
Addition/AkeaaUm Replace/Repair ❑
10
Applicant Name
r �d
Street Address
/�/ 's.�
11
Zip
City
State Phone
8
VENT: Fan (a):
EvapCooler(s):
Hood Is):
Duct(s)1:
Miscellaneous:
10
APPLIANCE:
Dryer(s):
Range(s):
Gas Log Is):
Wood Stove/
Solid Fuel: nS
Gas Water Heater(s):
11
UNIT HEATER(S): Wali 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
1000-175OM:
Other:
Pressure Vessel (cu. ft.):
15
COMPRESSOR/HP: Less than 3:
315:
15-30:
30-50:
50+:
16
GAS PIPING SYSTEM: Number of outlets:
17
HEATING SYSTEM: 1-100,000 BTU:
100,001 + BTU:
18
TYPE FUEL SOURCE: Electric ❑
Gas ❑ Oil
❑ ; Coal ❑ Wood ❑ ; Solar ❑
19
TYPE DISTRIBUTION: Forced Air
❑ Radiant ❑ 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/1 APPLICATION
OWNER OR l'Gv��t� �1G�22r�CJ DATE