1985, 04-25 Permit App: 00005174 Heat Pump ` 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
r,j-2/ :44// L2A- Project No.
2 Project- Address(Not Mailing Address) Space Zip
• /9.._`i.-!<iS/� Z r9i✓Yv , . ?14?--** .
3 City/Community State Subdi ision/Plat Name
4 Assessor Parcel No. Lot Block /
/7��E2 —L5c J 1:57 74/-
16 Contractor Firm Name Street Address
17 Zip City . State Phone
9924.E . 44/ Gam/', 91),:_G,3,3'=/7/,/
18 Contact Person License No. Phone if different than above
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: ,4ief Z'✓4�Z7,r�",2�/,/*
/4/570z-4. 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: Y N Floor: Y N Suspended: Y N
W
2
i 12/AIR
HANDLING:/ LING10,000 CFM or less: I More than 10,000 CFM:
O /.6R v TEM f/�iZ1/ S �/�
W 1 IG S BTU: 1-100M: 100-500M: 500-1000M:
U_
O
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
a
>I-
0 15 COMPRESSOR/HP: Less than 3: 3-15: 15-30: 30-50: 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets:
03
2
ZD 17 HEATING SYSTEM:1-100,000 BTU: 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric Gas ❑ ; Oil 0 ; Coal ❑ ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air," Radiant 0 ; Heat Pump
1* Number of separate zones for any heating, A/C or air handling system. F' _,2Q
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 APPLICATION --- .-----
OWNER OR ,--s‘- '247 DATE --- '.5