1986, 04-10 Permit App: 00010599 Mechanical Fixtures i
11 MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
F
1 Owner's Name (Last) .+ / st) (M) Department Use Only
/f-A.j,('.�Com. .„.... l Project No.
2 Project Address(Not Mailing Addr?$$) Space Zip
3 City/Community State Subdivision/Plat Name
4 Assessor P cel No. Lot Block
16 Contractor Firm Name StreekAddress
,----- Lam^ '-, +r 4 R�
17 Zip City j•-._,, State Phone
I
,
,Y`' ° � � ., ,,_ ( ) , rF'CP01s
18 Contact Person License No. Phone if different than above
8 Owner/Agent(If different than#1 above) ' I Busess Address
`--oma r-- 1, t1-v.\._9—",' I '+ r'=1 e�L^ ,/,/,<C,,)
g Zip City _ State Phone
15 Describe Work: (
New Addition/Alteration ❑ Replace/Repair 0
10 Applicant Name Street Address
//
11 Zip City State Phone
( )
* *
8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: Miscellaneous:
10 APPLIANCE: Wood Stove/
Dryer(s): I Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s): _ Q
I– 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
Z
W
d12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
0
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
LL
0
a 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
>-
I–
0 15 COMPRESSOR/HP: Less than 3: 3-15: 15-30: 130-50: I 50+:
Z
Q — —
CC
W 16 GAS PIPING SYSTEM:Number of outlets:
m
Z
17 HEATING SYSTEM:1-100,000 BTU: c Q-� /�% 100,001+ BTU:
d /C!
18 TYPE FUEL SOURCE: Electric 0 ; Gas Oil 0 ; Coal 0 ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air "c ; Radiant 0 ; 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.
i PA
ALDENDORF FoRNA
SIGNATURE OF tk BION j' L,L1r8HEATING, APPLICATION '/
i OWNER OR . i 'a EeN AVE. DATE Y`'/G a c�
1POY WE,WF_99206
2