1986, 12-26 Permit App: 00014613 FireplaceMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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Project ff / //1'
GJ
Owner's Name Last /' First MIS/
C 4141 ��L�t
Project Address (Street Name & Number)
I 09017 / cl
City((
State
LLJr i ��
Subdivision/Plat Na:
Assessors Parcel #
/651-2— l 6D
Lot S
Block,
Plat #
Applicant
Address
City
State
Zip
Phone
Business Phone
Contracto _ -
It) lJ V l t V, fi 0 f %A 0— -- ( il.i f �
Address
rC ` t 3og. r " 1
City,State
PoK e
LC) A,
Zip
Q zo
Phone
5'.?cc-F7 ye
Cont j��
'` I t c
License
' c SI �s� .SCS
Business Phone
Describe Work t !V� - > \- C-� car 1 jz. --Lp e' t ,.. s& -
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
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10.,,:.00+BTU
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
OWNER OR
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APPLICATI f2_ —2 6
DATE ((