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