1985, 11-12 Permit App: 00008826 Furnace, Piping •
. . MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
•
1 Owner's Name (Last) / (First (M) Department Use Only
i)CCr✓! � �� Project No. ,26
2 Project Address(Not Mailing 7 cR Addr
/ess) Space Zip
/ �'J .L,c-,,L`.. t._/ '
3 City Community U State / Subdivision/Plat Name
4 Ass6ssor Parcel No. Lot Block
(ob)
16 CzIracfor Firm Name„ s Stre t�A�ddress
C' LC. . /l . /Cti (1 ,r' `-..' '. 1
17 Zip c.' City / State Phone 7'. /
18 Contact Person /License No. Phone if different than above
i'
- - ,f<1_2--.Z.-� ''/- rr/ -- / .PY N
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work:
1 New ❑ Addition/Alteration ❑ Replace/Repair ❑
10 Applicant Name Street Address
I
11 Zip City State Phone
* : *
8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: Miscellaneous:
10 APPLIANCE: Wood Stove/
Dryer(s): Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
I- 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
Z
W
2
d 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
5
0
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
U-
o
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
a
I-
O 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets:
m
2
Z• 17 HEATING SYSTEM:1-100,000 BTU: /Q,j, C'c� � Cq 7 4_2z 100,001+ BTU:
- .5
18 TYPE FUEL SOURCE: Electric ❑ ; Gas ...,b< Oil 0 ; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air j" Radiant ❑ ; Heat Pump
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 I) /,-.)--e---,./-6(-4...-� APPLICATION// /
OWNER OR ,T 5', - DATE