1984, 09-26 Permit App: 00002621 Furnace y w
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19 , - MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M) Department Use Only
--r ,,/n 6.--)4° Project No.
2 Project Address(Not Mailing Address) Space Zip
3 City/ mmunit•727/2.- State z Subdivision/Plat Name
4 ssessor Parcel No. Lot Block
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16 Contractor%Lf/Firn ri I Street Address
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17 Zip T City State JI Phone
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18 Contact Person O License No. Phone if different than above
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work: /
i New ❑ Addition/Alteration ❑ Replace/Repair ET
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): I 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
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a 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
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W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
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W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
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O 15 COMPRESSOR/HP: Less than 3: 3-15: 15-30: 30-50: 50+:
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W 16 GAS PIPING SYSTEM:Number of outlets:
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Z 17 HEATING SYSTEM:1-100,000 BTU: 4-1^f ere) 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas 15"; Oil ❑ ; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant ❑ ; Heat Pump El
I
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 ttxgffmance of
construction.
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SIGNATURE OF / APPLICATION
OWNER OR ,-� ,,z_/--/ ,t.JP� DATE 9-_ - 7-‘7(