1984, 08-17 Permit App: 00002267 AC .:
• MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
•
1 Owner's Name (,41t) l (First)
Z1//����r/(jj (M) Department Use Only �.j /) /_
.6 t'.. o___. d6ii t__. Project No. ,4p LD
2 Project Address(Not Mailing Address) rt Space
Zip
• /(.2/1 .! '' • ldiC I c --
3 City/Community State Su{b'ddiiiviision/PleattName p [/j�VC/
/// i, / -.
4 Assessor Parcel No. ` ' Y74 r P 4�!Cl
Lot � Block
2 53 ,- ^3 i /3 3
16 Contractor Firmem Street Actress
17 Zip 0m . ) �:1" a&C
!1_e.,-)— .f s.— t5, � J� 1
City State 0 Phone
7 ha "above '`
18 Contact Person License No.
Phone if different than above /
7 '_ e3K _ ,",, ./f"..-
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City I State I Phone
15 Descri/�/}Work: �¢ ( )
.01;47t //i7t FZ.L L L i-New 0 Addition/Alteration ❑ Replace/Repair ,l
10 Applicant Name / � � Street Address
':-)711 Zi L^' L'� p E� t°t l � i
�1 vie zc'4t 6 'E2t3) .._
p City1 State f Phone
qr / r--
* *
8 VENT: Fan(s): Evap Cooler(s): I Hood(s): IDuct(s)1: Miscellaneous (--;-
tr10 APPLIANCE: I
Wood Stovel 6'l�r4 � � A-
• Dryer(s): I Range(s): Gas Log(s): I Solid Fuel: Gas Water Heater(s):
-I— 11 UNIT HEATER(S): Wall Mount: Y N I Floor: Y N
Z I Suspended: Y N
W
2
a 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
5
0 •
W 13 REFRIG SYSTEM BTU: 1-100M:.4 —
W , 100-500M: 500-1000M:
0
W 14 1000-1750M: Other:
a Pressure Vessel(cu.ft.):
} •
I-
0 0
15 COMPRESSOR/HP: Less than 3: 13-15: 15-30: 130-50: 150+:
Q
CC 16 GAS PIPING SYSTEM:Number of outlets:
m
2
J 17 HEATING SYSTEM:1-100,000 BTU: 100,001+ BTU:
Z
18 TYPE FUEL SOURCE: Electric ❑ ; Gas ❑ ; Oil ❑ ; Coal ❑ ; Wood ❑
Solar ❑
19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant ❑ ; 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.
SIGNATURE OF
OWNER OR kV) (75)--)
l ` �'I r� APPLICATION ,-, dai ,./4./.4..1 ._ DATE 7