1985, 12-30 Permit App: 00009261 Piping • MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project# Q/1176/ /,1`
Owner's Name Last First MI �—C
A1.1=s st;AL1 �J A/40yr
Project Address(Street Name&Number)
q0 ,L kill-f Ami 776
State Subdivision/Plat Name
Assessors Parcel# Lot Block Plat#
Applicant Address
l?h�4t� y /t=I-1.kt- v 54°2 ' M77 '-'-
City State Zip Phone
Business Phone
;/: 6
Contractor Address
City State Zip Phone
Contact License# Business Phone
Describe Work
Fans Evaporative Cooler Hoods Electric Furnace/Ducts Miscellaneous
Dryer Range Gas Log Gas Water Htr. Solid Fuel/Wood Stove
0-10,000 CFM 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 15-30H P 30-50H P 50+HP
1-5 Outlets 6+Outlets
Gas Piping
Gas Fired Heating System 1-100,000BTU 10v,.;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 JZ% 1 APPLICATION
OWNER OR it' .DATE /-2 -