1984, 11-12 Permit App: 00003376 Mechanical Fixture -
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (L ) (Firs(. 9 (M) Department Use Only
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2 Project Address(Not Mailing/)ddress) - Space Zip
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3 City/Community State Subdivision/Plat Name
4 Assessor Parc. No. Lot Block
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16 Conp.asfor Firm Name r j:-.A.),_.
St Address
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17 Zip City,, State Phone
18 Contact Person c�� icense No. _ Phone if different than above
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8 Owner/Agent different than#1 above) , Buseess Address
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9 Zip City State Phone ///7
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15 Describe Work:
New Addition/Alteration 0 Replace/Repair ❑
10 Applicant NameStreet Address
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11 Zip City State Phone
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8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: Miscellaneous I
10 APPLIANCE: Wood Stove/ C-f-7_ - "�� J
Dryer(s): I Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
Z 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
W
2
IZ 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:
LL
0
11.1 d 14 1000-1750M: Other: Pressure Vessel(Cu.ft.):
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F-
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0 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets:
m
2
Z 17 HEATING SYSTEM:1-100,000 BTU: 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas ❑ ; Oil ❑ ; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant ❑ ; Heat Pump
1* Number of separate zones for any heating, A/C or air handling system. 2
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 OFf; APPLICATION �c
OWNER OR � ` t- `tqs ----X--"'"A)."6- -e x=' DATE %
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