1986, 09-19 Permit App: 00013209 Insert MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
AS
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Project# 5Z�,C�y 9
Owner's Name Last First MI
L tt.11DeRQ t s-T' DAV 1t 1l1/
Project Address(Street Name&Number)
N 61I Vae-T +
City State a Subqvi'ion/Plat Name
-Ili E — k 1< 2. /
Assessors Parcel# /(05.1
/(0S1 /n / / Lot ` Block Plat#
Applicant f G- Address
City State Zip Phone
Business Phone
Contractor Address
City State Zip Phone
Contact License# Business Phone
Describe Work
Fans Evaporative Cooler Hoods Electric Furnace/Ducts Miscellaneous
Dryer Range Gas Log Gas Water Htr. Solid Full/Wood Stove
0-10,000CFM 10,000+CFM
Air Handling Units
Refrigeration Systems! 1-100M 101-500M 501-1,000M
Heat Pumps(BTU)
1,001-1750M Over 1750M
Compressor 0-3HP 3-15HP 15-30HP 30-5OHP 50+HP
1-5 Outlets 6+Outlets
Gas Piping
Gas Fired Heating System 1-100,000BTU 10v,: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 an st- - of loc. laws regulating construction or the performance of
construction.
SIGNATURE OF ` PLICATION
7/ q
OWNER OR .DATE