1985, 01-03 Permit App: 00003857 Furnace MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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1 Owner's Name (Last) / (First) (M) Department Use Only
Ga /dt.�� C�,s'O_.,- Project No.
2 Project Address(Not Mailing Address) J Space Zip
3 City/Communitfty- State // Subdivision/Plat Name
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4 Atessor Parcel No. Lot Block
1155 1102=
16 Contractor Fir Name 'Street Address
/1/( /I% tell Irj I 6
17 Zip City State // Phone
18 Cont P o 0 /
` -j!�O XI/L.moi' �.A.5 Z. ( )��b/ 5-t��..7i/
® License No. Phone if different than above
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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:
a
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
W
2
a 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
5
0
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
W
0
a 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
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0 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
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WQ V.
16 GAS PIPING SYSTEM:Number of outlets:
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2
Zo 17 HEATING SYSTEM:1-100,000 BTU: S OS t(�C�C% 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas GY; Oil ❑ ; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant ❑ ; Heat Pump El
1* Number of separate zones for any heating, A/C or air handling system.
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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 .,1,04:_%>---7,2 APPLICATION - -
OWNER OR 1- c. % ,.�,:'7).-",, DATE A ,, - ; c,-