1986, 03-24 Permit App: 00010162 Furnace, PipingMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT ANDCOMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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 giveauthority to
violate or cancel the provisions of any state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR
APPLICATION
DATE 3- z V- J'r!v
Project# /r /&----
&----Owner's
Owner's Name Last First MI
ot41(5 POAMLo 4,
Project Address (Street Name & Number)
E. Ivo z f iA-,t1N®.ti/
City„State
7/*
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eviirsff 9 2-/'
Subdivision/ lat Name
�VAL-/
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Assa.krs Parcel #5 ! J o /
1
Lot i
Block /
LTL
Plat #
Applicant
Gto/r1 , a,,,s/fr Lo e- ,
Add ess
4 ivv v fg,f,✓a/e,./
City
Sp 7 f t°
State
c: sr{
Zip
2-1- 2---
Phone
92-6' —tltr%O ,
Business Phone
Contractor
Address
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
Air Handling Units
0-10,000 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
i
1
6+ Outlets
Gas Fired Heating System
1-100,000BTU
'
10.,,.:00+BTU
--.7,-
-a7. OC.7
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 giveauthority to
violate or cancel the provisions of any state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR
APPLICATION
DATE 3- z V- J'r!v