1986, 08-13 Permit App: 00012664 Heater, Piping MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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Project# //�
Owner's Name Last First MI �-b
Project Address(St t Name 8.Number) :^r
/i f())4 ,7cct r o 496/42)
City State Subdivision/Plat Name
LS�'�y�,�, 1� , L,Gv(v�tzs 1-rc PLACE
Assessors Parcel# '/IA .e)-74/ _( / Lot Block Plat#
Applicant ! + � Address
City State Zip Phone
Business Phone
ntractor Ad ss
olreo idfr- xi 7//'-; £ 4/C &_�/ 7 /t2r
City State Zip Phone
�SC'c)e/9- els C1- 7,-i/1Z, `5 -3 c7-- 7.5.--
Contact )_ License#. /1 �/ 7 Business Phone / 41-6 73
Describe Work _
Fans Evaporative Cooler Hoods Electric Furnace/Ducts Miscellaneous
Dryer Range Gas,i.eg---*, ,.y,y 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 30.50HP 50+HP
—
1-5 Outlets j 6+Outlets
Gas Piping
Gas Fired Heating System .----- 1-100,000BT�_ 10v, 00+BTU
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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 APPLICATION /
OWNER OR 1 " C'�-/ ' 7 DATE7