1984, 11-08 Permit App: 00003258 Furnace MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M) Department Use Only
Pete /7N1a4., Project No.
2 Project Address(Not Mailing Address) Space Zip
/V4 i'-^) .s SS 4-,(/ /tzd,'- 4
3 City/Community((( State Subdivision/Plat Name
4 Assesssocel No. Lot Block
( /�5
16 Contractor Firm NameStre
/J et Address �j}
,%Dk..eLi 117'J' 2' r7,,,,(7lJ��Y /v, 31 2 �� "Pe,4_
17 Zip ` `,n ")/7:--_,City State Phone
�jq� '/ �}
18 Cont t Person C License No. Phone if different than above
8 Owner/Agent(if different than#1 above) Business Address
g Zip City State Phone
( )
15 Describe Work:
New ❑ Addition/Alteration ❑ Replace/Repair ❑
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): Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
Z 11 UNIT HEATER(S): Wall Mount: V N Floor: Y N Suspended: Y N
W
2
a 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:
U-
O
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
a
>-
I—
O 15 COMPRESSOR/HP: Less than 3: 3-15: 15-30: 30-50: 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets: /
co
2
Zj 17 HEATING SYSTEM:1-100,000 BTU: / Soy 6dG "3 r-t,� 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas it6 ; 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 O. co
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 OFe_4(. 4) APPLICATION �(�
OWNER OR - � DATE / r , /?-7-5/