1985, 09-23 Permit: 00007828 Insertt T lao .
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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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 X
�J C���YGS APPLICATION/�3 A��
OWNER OR DATE _
Project M iJ
Owner's Name Last First MI
dLICS CE_0fz6 L
Project Address (Street Name & Number)
City
SPCK
State /
Subdivision/ Plat Name
At�0 "a:' fl�l2A�l�Gi*�'
Assessors PParcc�l Z
Lot
Block/
Plat M t Z _
Applicant ^
Address
City _T
State _T
1p
Phone
c -12g 1S 4A
Business Phone
4 44—(0
Contractor
Address
City
State _T
1p
Phone
Contact
License M
Business Phone
Descrit>�rk
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/ Wood Stove
Air Handling Unita
0.10,000CFM
10,000+ CFM
Refrigeration Systema/
Heat Pumps (BTU)
1-100M
101-500M
501-1, 000M
1,001-1750M
Over 1750M
T777�
Compressor
3-15HP
15.90HP
30-50HP
50+HP
Gas Piping
1-50utleta
6+ Outlets
Gas Fired Heating System
1-100,000STU
10u,v00+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 X
�J C���YGS APPLICATION/�3 A��
OWNER OR DATE _