1985, 12-07 Permit App: 00009062 Insert •
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
SFR
1 Owner's Name J(Last) Fir t) Department Use Only
L c E.v e A/-�� Project No. �r Or-
2 Project Address(Not Mailing Address) - Space Zip
C / 6'/2 14,4:4-_r el s vak `1 ri 21 2-
3 City/Community State Subdiv' ion/Plat Name
G. . [-A-tHeR P�4 tcK
4 Asses 'r Parcel No. Lot Block
531 — OS()2'' 3 i/ 86
16 Contractor Firm lame Street Addre s
1, fri f (e fn.c. 1 /e vv 'pecne
17 Zip City / State Phone
,9'/20 j / t _, , (5-C(-1. ) 3)c y5 y7
18 Contact Person 7 License No. Phone if different than above
0cw~` A/4Aes/nr . . , G%V,OC 1 (77/(/1 "` _
8 Owner/Agent(if different than#1 above) Business Address
/
9 Zip City State Phone
( 1
15 Describe Work:
I New Addition/Alteration ❑ Replace/Repair E
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/ =ct?p!4 c e
Dryer(s): Range(s): Gas Log(s): Solid Fuel: 1-#, e✓ Gas Water Heater(s):
I- 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
Z
aW //
12 AIR HANDLING: 10,000 CFM or less: 1 / More than 10,000 CFM:
5o
V
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
LL
0 -
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
CL
>-
I- '0 15 COMPRESSOR/HP: Less than 3: 3-15: 15-30: 30-50: 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets:
m
2 J �
O 17 HEATING SYSTEM:1-100,000 BTU: V 100,001+ BTU:
Z
18 TYPE FUEL SOURCE: Electric E ; Gas ❑ ; Oil ❑ ;; Coal I=1 ; Wood 111.-',' Solar E
y
19 TYPE DISTRIBUTION: Forced Air HCl.; Radiant Com' 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 //�_e ✓J�„ f 6 DATE
cAPPLICATION f� ,/�S.
OWNER OR 1l2 .