1984, 10-16 Permit App: 00002919 Furnace*
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last)n ^(First) (M)
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Department Use Only
Project No.
I
2 Project Address (Not Mailing A rasa) C---Space Zip
.-- 21/2 (JN/,G N Pc/ P;Poi •C
3 City/Community
State [
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Subdivision/Plat Name
4 Assessor cel No.
Lot
1 Block
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16 Contr tor Firm Name
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Str==M ddrresss
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7 Ct.
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State
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one
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18Contact Person
License No.
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Phone If different than above
8 Owner/Agent' (If different than #1 above)
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Bu ass Address 1
C. ./.76,)- S. 'i
9 Zip
City
State
Phone
15 Describe Work: x`11
New / �X1 Addition/Alteration ❑ Replace/Repair ❑
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
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): Wail 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. ft.):
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: Ty
/Gas
100,001 + BTU:
❑ ; 011 0 ; Coal 0 ; Wood 0 ; Solar 0
18 TYPE FUEL SOURCE: Electric > ;
19 TYPE DISTRIBUTION: Forced Air (; 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 r.-,
OWNER OR t'
APPLICATION
0 e Le DATE /d —/!e —0,°',$1