1986, 02-27 Permit App: 00009828 Furnace r
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AID COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
2e1C ) Project# /i nF
Owner's Name � 'yrla7-e 7� Fire MI
Project Address(Street Name&Number)
/3-70U e, E/
City 1 State S Ivlsion/P Name
tete—.. L 6-- VEr4
Asses orP cel# • / Lot Block Plat#
64-
Applicant Address
\..._.. . .-'.'" � -7 /3 7),-. e - Il rd
7 City , State Zip Phone G�
4/2„.46e® 7,r�r , g��/4' 9� -c34/ (/
Business Phone
Contractor Address
(010 - i'. o. I.I • �o2
City State Zip ,, Phone /
*1-5,e- Li- (t_) __ 9,2? 0 �f��1/7�•-1 :z1J
Contact - License# Business Phone
5 /�t r /uia- = * 3Zi —
Describe Work ` 2Z"' " '
Fans Evaporative Cooler Hoods Electric Furnace/Ducts Miscellaneous
Dryer Range Gas Log Gas Water Htr. Solid Fuel/Wood Stove
0-10,000CFM 10,000+CFM
Air Handling Units
Refrigeration Systems! 1-100M 101-500M 501-1,000M
Heat Pumps(BTU)
1,001-1750M Over 1750M
Compressor
0-3HP 3-15HP 15-30HP 30-50H P 50+HP
1-5 Outlets 6+Outlets
Gas Piping
Gas Fired Heating System 0/510/
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 6if / jn DATECATION ��
OWNER OR /115/9 Zi��Z e �l�� GX