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1986, 12-10 Permit App: 00014485 Furnace, Piping 12246 v MECHANICAL PERMIT APPLICATION WORKSHEET 4s PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND Project# ii 435 Owner's Name Last , First GK�-� MI r Project Address(Street Name&Number) City State Sub i inion/Plat Name 2 STROM 1 PLOT Assessors arcel# /(051/1 y O L S Lot Block n Plat# Applicant Z Address L-_ City State Zip Phone Business Phone Contractor's > Address City State Zip Phone 277-'64 Contact i License# _ Business Phone g/4-P/' S; /f` / l'/ ' 7— e, rel V Describe Work 7+l ��� �y 6Fans Evaporati'e • er 6 Hoods Electric Furnace/Ducts Miscellaneous Dryer Range Gas Log 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 30-5OHP 50+HP 1-5 Outlets / 6+Outlets Gas Piping Gas Fired Heating System 1-100,000BTU 10,,,L00+BTU 6'0. �� i :I --.1:- 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. SIGNATOWNERUOROF �1 %&� DATECATION >. //i /f6