1984, 10-23 Permit App: 00002981 Furnace MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name i /- (F rst) //�/ �(Ivl) Department Use Only
�qV i/� - Project No.
•
2 Projec},Address(Not Mailin ddress) • Space ip
3 Ci unity • . State Subdivision/Plat�l1Name
4 cAs7�riv No.,_4 Lot L// Block £/,v f V erS 7, P/€' e,
"Y5 C' I /6'6 60 2- F/
16 Contrac : -, :1 , �� St re 5Addi: i// 7,...;e4)._t___.
17 Zip ��� Cit St Phone(Phon(i2X2 .. 4 � —�'
18 Contact Person License No. Phone if different than above
��7- .rA --&--i- A &
8 Owner/Agent(if different than M1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work:
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
d 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
5
0
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
LL
0
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
a
>-
I-
0
0 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets:
m
Z 17 HEATING SYSTEM:1-100,000 BTU: 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric 0 ; Gas/X; Oil 0 ; Coal ❑ ; Wood ❑ ; Solar 0
19 TYPE DISTRIBUTION: Forced Air KI ; Radiant ❑ ; 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 ,,.-/ G
-? -1 , eC l� APPLICATION/ //71.5.--7
� �i
OWNER OR f.--4-1 ' .� .DATE � `�