1985, 04-01 Permit App: 00004783 Furnace•." •/2_4
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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1 Owner's Name (Last) (First) (M) Department Use Only
T/L%3ffr? % /1-j9, TA/Y Project No.
2 Project Address (Not Mailing Address) Space Zip
A/. / 7/3 6v/4-6 o cv
3 City/Community
IN
State
/vim .
Subdiv ion/Plat Name Ad
,L(r-u�/ oh Ac /
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4 Assessor Parcel No.
Lot
Block
16 Contractor Firm Name
/7/6-,9r % RNS cr/2, _div C.
Street Address
E• "676, /77a/v7--a Y
17 Zip
93..?0(;
City
Q7;PC) /'er,/ t=
State
Phone
(S)?) 9;3c -/1/3
18 Contact Person
fRG/C_ 0/60/Et
License No.
r/E'"7r/-//1 z.ry
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
(
15 Describe Work:
New C Addition/Alteration Li Replace/Repair
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( 1
8 VENT: Fan(s):
Evap Cooler(s):
Hood(s):
Duct(s) 1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
Range s):
Gas Log(s):
Wood Stove/
Solid Fuel:
Gas Water Heater(s):
11 UNIT HEATER(S): Wall Mount: Y N
Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. 1.):
15 COMPRESSOR/HP: Less than 3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU:
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas; Oil ❑ ; Coal ❑ ; Wood L: : Solar
19 TYPE DISTRIBUTION: Forced Air Ll ; Radiant ❑ ; Heat Pump CI
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
OW NER OR
APPLICATION
DATE - -