1984, 12-06 Permit App: 00003683 Fireplacew
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS.OF.THE FORM YOU UNDERSTAND
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1 Owner's Name (Last)first) )I Department Use Only
1 E-42---.- Project�lo.
2 Project Address (Not Mailing Adt rens) Space Zip
EA 44tA)l`*-�5t �-�iC.l Cr0 �
3 City/Community
3 t.
St to
..y..._P-
Subdivision/Plat Name
C60-4./ Q wAI 2rrd /c4f
4 Assessor Parcel No.
Zest/. 3026
Lot 1
26 1
Block
/9
ea
16 Contractor Firm Name (
API* i ..c P- Q s Ali ,
Street Address `�
el. 1 ru,csU
17 Zip "�
- (
City �/ ��
Iv��"�
State
k.
Phone°ea(U ( ,' t /
( () 4 O4' 2.&-i U
18 Contact Person
License No.
74 _
/ 02-P-fj,,� 1-
Phone If different than above
8 Owner/Agent (If different than #1 above)
Business
Address
g Zip
City
State
Phone
( )
15 Describe Work: ( L.SrA4u/
New 0 Addition Alteration
� i Lr
❑
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:I
Dryer(s):
1 Range s):
Gas Log(s):
Wood Stove/
Solid Fuel: ,,h(a---
Gas Water Heater(s):
11 UNIT HEATER(S): Wall Mount: Y N
Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. t.):
15 COMPRESSOR/HP: Lessthan3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU:
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric 0 ; Gas 0 ; OH 0 ; Coal 0 ; . Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; Heat Pump
1* Number of separate zones for any heating, AIC 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.
SIGNATURE OF
OWNER OR
APPLICATION 2 jj e (J
DATE (