1985, 06-21 Permit App: 00006301 Heat Pump E . .
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project#
Owner's Name Last Firs MI
�f/( 4,lL� /Irfdf"i!"
Project Address(Street Name&Numll6r)GG{ /
S 1//I N., I / 1; / _
City State Subdivision/Plat Name
Ads
Assessors Parcel# Lot Block Plat#
Applicant i Address
kid Al.,TI,C,1 ?ItYA-je'X.-0 -, - / 2
City z U e Zip Phone
Business Phone
Contractor Address
/e./(‘:_,
Cityc. State , Zip Phone ,/
�.n�.- iLk 99e) 5`�G/-//70
Cont t I License# Business Phone
a kd et& , 1 -ad-- - a''2 -/117'
Describe Work
letieDt
Fans EvaporativeCooet r�Hoods Electric Furnace/Ducts Miscellaneous
Dryer Range Gas Log Gas Water Htr. Solid Fuel/Wood Stove
0-10,000 CFM 10,000+CFM
Air Handling Units
Refrigeration Systems/ 1-100M 101-500M 501-1,000M
Heat Pumps(BTU) , /Z70--
1,001-1750M Over 1750M
Compressor 0-3HP 3-15HP 15-30HP 30-50HP 50+HP
1-5 Outlets 6+Outlets
Gas Piping
Gas Fired Heating System 1-100,000BTU 10,,,;.00+BTU
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 ORf - /.t1,/ .DATEZ/ S