1985, 01-22 Permit App: 00004064 AC*
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS QE THE FORM YOU UNDERSTAND
1 Owner's Name (Las ( t) (M)
, / /
Department Use Only
Project No.
2 Project Address (Not M iling A rens) Space Zip
%? • 79-3 2J1 gr/a-7
3 City/Community
State
Subdivision/ Plat Name &ab a5/ -.e
4 Assessor Parcel
6/5C1/ --- l )Q /8
Lo
I Block
Il
/e(e-Ki.
16 Contractor Firm Name
,t-�h
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Street Address
`Aa' A . ,5707
17 Zip
9
City
�'
State
6e—.97/_)
Phone
«q—,7$ —6
18 Cont: t n
L -...,Il. J,./-
P
cense No.
--
—
Phone if d' ferent than above
8 Owner/Agent (if different than 41 above)
Business
Address
9 Zip
City
State
Phone
( )
15 Describe Work:
New 0 Addition/Alteration
0
Replace/RepaIl
10 App
nt Name
A .e .�.— �6
Street
Address --)14-6Z--... ,� //JJ
11 Zip
9 Ifo
City
0�5� �
State
Phone
6 ) 909-a..-- 7/0C,
8 VENT: Fan(s):
EvapCooler(s):
Hood(s):
Duct(s)1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
I
Range s):
Gas Log(s):
Wood Stove/
Solid Fuel:
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: Less than 3:
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 ; Ga: 011 0 ; Coal ❑' ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; Heat Pump
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.
SIGNATURE OF
OWNER OR
gte.u�22e
APPLICATION l
DATE'