1984, 12-28 Permit App: 00003818 Furnace • ..
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND y-
1 Owner's Namee/ (Last *first) �4 dvl)� Department Use Only
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2 Project A dress(Not Mailing Address Space Zip
10• /2/9 w� �7
3 mm ity State
',G',�,/.C� Subdivision/Plat Name
4 ssessor Parcel No. Lot L=/V' Block
16 Co tr for F'rm Name j/`� ' e/e/) Streetges /
1 Zip Ci State Phone
18 Contact Person License No. Phone if different than above
8 Owner ent(if different tha #1 above)
BusinessAdd s
Z- �/ _ GTS /_.., ? ��ES /�
9 Z �j� City State Wei'l . 27Ph'f.,t'kg-- I /� Phone Q? '/ 9 76-•
699)
15 Describe Work:
New ❑ Addition/Alteration 0 Replace/RepairX
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): I Range(s): Gas Log(s): I Solid Fuel: Gas Water Heater(s):
Z 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
W
2
a 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
5
a
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
LL
0
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
d
>-
I—
O 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets: /
GO
Z —. ��b00 Tit
D 17 HEATING SYSTEM:1-100,000 BTU: ��` 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas/ ///,P‹; Oil ❑ ; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air X'; Radiant 0 ; Heat Pump ID
1* Number of separate zones for any heating, A/C 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.
SIGNATURE07‘;:---1 APPL ICATIO
OWNER OR ' %% ..4 4c......; a DATE v^�`� ��