1987, 10-20 Permit App: 87003596 Furnace, Piping .>.
MECHANICAL PERMIT APPLICATION WORKSHEET �`�
G)
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
qe, x 132— Srtz 56 ,
1 Owner's Name (Last) (First) (M) Department Use Only
7g././V `...J -.fe/Q_Y Project No. VJ
2 Project Address(Not Mailing Address) Space Zip
3 City/Community State Sub1E.4-Tt4
islon/Plat Name j�
-���C�/ i9 til `, ,�[ ' t kk
4 Assessor Parcel No. Lot Block
16 Contractor Firm Name (_/ Street:address
17 Zip i/ City 1 State Phone
l9 ') - ./ ---2-1-,----- /' (`-�/,t'') 9���'-(57,-(76-,,2__,
18 Contact Person Licensee No. Phone if different than above
41119.200041
8 Owner/Agent(if different than#1 above) I Business Address
g Zip City State Phone
( )
15 Describe Work:
1 New ❑ Addition/Alteration 0 Replace/Repair 0
10 Applicant Name Street Address
11 Zip ' City State Phone
( )
i
* I *
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):
I— 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
Z
W
2
d 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
5
0
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
W
0
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
a
>I-
O 15 COMPRESSOR/HP: Less than 3: 3-15: 15-30: 30-50: 50+:
Z
` \
W 16 GAS PIPING SYSTEM:Number of outlets: / I ` 6-6
Do l /
Z• 17 HEATING SYSTEM:1-100,000 BTU: 7 \ -?1 9 .- -g---- 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric 0 ; Gas )'; Oil 0 ; Coal 0 ; Wood ❑ ; Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; Heat Pump 0
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 APPLICATION
OWNER OR DATE /D��G/�7