1984, 10-26 Permit App: 00003047 Furnace MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name as (Fipst}- ,1(M) r Department Use Only
(71
`,(-� //�, Ir Project No.
2 Project Address(Not ailing Ad ess) Space Zip
-. i' _- T WC)' '
3 .mmun; State Subdivision/Plat Name
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\� �LA-'' LA �p,G`e/ ce/tj, p/
4 A sessor Parcel No. Lot Block
16 Con a F' a St , d )5-
/ --7--,c)
17 ip / City x z rm i State Phone )L,. 5 2/ 75
18 Contact Person License No. Phone if different than above
2 2 _574#V
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work:
New Addition/Alteration ❑ Replace/Repair 0
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
EL 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
5
a
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
LL
0 -
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
a
>I-
O 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
Z
Q
w 16 GAS PIPING SYSTEM:Number of outlets: /
CD 1
2
Z 17 HEATING SYSTEM:1-100,000 BTU: /J 0 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric 0 ; Gas; Oil 0 ; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air ; Radiant 0 ; Heat Pump El
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.
SIGNATUREF NayAdll ,% APPLICATION
OWNER OR / -..e.' a .✓ DATE C'46.- �