1986, 05-19 Permit App: 00011188 Heat PumpMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE 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 Taws 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 APPLICATION —6
OWNER OR DATE
Project 0 f / / SO
Owner's Name Last FirstMI
m trS-tete-C-4 -r s g'
Project Address (Street Name & Number)
- ci s'o Si N-!-tii _
City
#
State
Subdivision/ Plat Name
Assessors Parcel
Lot
Block
Plat #
Applicant`
_Y.N 1.4—q00, 0,...t.„46i.‘......... ....Q........-
114. %
Address
1-3 I. k3
;1.544).- State �
LJv . i M -
Zip
4::?.�Z 7.43 1
Phone
-6 ,s—rf'crb
Business Phone
Contractor
Address
City
State
Zip
Phone
tact.
License �.{..L.4.-A)' + _ CC CC 1 e
Buri ness Phone
Descr Work
,,
t 61••
Fans
Evaporative Cooler
Hoods
EI is Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/ Wood Stove
Air Handling Units
0-10,000CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M Ng
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+ HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,0008TU
1Q,,� 00+BTU
0."...-c......„ .6c...4.__. i s-cre....-
...-xl-.
I certify that the above information as submitted by me is true and correct and further, agree that all pro-
visions of Taws 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 APPLICATION —6
OWNER OR DATE