1984, 08-07 Permit App: 00001646 Furnace, Heat Pump MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (L X11 st) (M) Department Use Only
Project No.
2 Project Ag-dress(Not Mailing A•dress) Space Zip
so l LIJ )--1 1.(.)-61x),( .C. bb
3 City/Co munity State 1Subdiv' n/PI t Name /rt ��1�
111-0-- ._ a J 1 /c7 Uri%& ,c S6
4 Assessor Pal No. , Lot Block
2/65 - o&a8
16 Contra for Firm Name , treet Address
in
17 Zip
/ City Sta/te/ ^ j Phone
L-I /'
! ��✓✓))\ \_r l/���1 ( ) iv sv— L/07C?
18 Contact Per n License No. Phone if different than above
-J2-1?) c;/c1"):,; CD -(2 /i- /-/C- -.►'!
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work:
1 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: I Wood Stove/
• Dryer(s): 1 Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
I— 11 UNIT HEATER(S): Wall Mount: Y N Floor: V N Suspended: Y N
Z A:
W
a '
_• 12 AIR HANDLING: 10,000 CFM or less: j C) c-I ---1 More than 10,000 CFM:
O t f
C!
W• 13 REFRIG SYSTEM BTU: 1-100M: ' 100-500M: 500-1000M:
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
a
>-
I—
O 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
Z
W 16 GAS PIPING SYSTEM:Number of outlets: J °/'i'41
m
2
Z 17 HEATING SYSTEM:1-100,000 BTU: 70/ CAD rU 1
14 I 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas i ; Oil 0 ; Coal 0 ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air /1 ; Radiant ❑ ; Heat Pump
1* Number of separate zones for any heating, A/C or air handling system. "LE.60
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 OFAPPLICATION (�
OWNER OR �) SZ 5_..� -Q ;l DATE .l l J ,( 1:i /f g /-