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1986, 03-20 Permit App: 00010130 Gas Line MECHANICAL PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND Project# f n 13 0 Owner's Name L Last First MI ff V1 J -e�/�e n i-i'o fe. Are. , 7 Project Address(Street Name&Number) N' loy t4,/ i ',- City State Subdivision/Plat Name Spo AQ n 2 , ,s% IV IJ I arL1l r4( , 011.-1\U4 fir( _ A ss r GGI�I�reel ,, 1eLot G Block —7Z, Plat M Applicant Address !J Chet_i-..f i-e i-- //fD 3 / f -vio:�>City State Zip Phone VoA a,, e c-e./Q-_s- 97 z a.‘ Business Phone Contractor Address /—o U k 57`a,A- 5.e_ t vie. e 4%"/�✓`&? /—'a. cf L,,e City StateZip Phone Soa/� 4 e "„4, , pPae6 7p? 6/- 9,5 f ntact License# Business Phone FOO(L..S t I(4 PI-4 / I Describe Work 1/91 a 1.----e ;/ cts. p /n.� ( ,(P /7 r) Co'1--C, Fans Evaporative Cooler Hoods Electric Furnace/Ducts Miscellaneous Dryer Range Gas Log Gas Water Htr. Solid Fuel/Wood Stove G.----- Air Handling Units 0-10,000CFM 10,000+CFM • Refrigeration Systems/ 1-100M 101-500M 501-1,000M Heat Pumps(BTU) 1,001-1750M Over 1750M Compressor 0-3HP 3-15HP 15-3OHP 30-50HP 50+HP 1-5 Outlets 6+Outlets Gas Piping Gas Fired Heating System 1-100,000BTU 10.,,:00+BTU 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