1986, 05-13 Permit App: 00010916 Heat Pump MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project* 1 �,C-1 I /,
Owner's Name Last irst MI f (L'
6LAek ids
Project Address(Street Name&Number)
N• a6li c ) _
City State Subdivision/Plat Name
Assessor arcel# Lot Block Plat#
Applicant Address
City State Zip Phone
Business Phone
Co ractor p Address
F,'-/s2 7/ ` t.,
Cit State li'l./A-- Zip Phone
. 49 ,�' 9C2V6 ?_,1-r i b I;
Conti, , `- LLei cense# Busin _ •hone
•...���►►►... r ` -� /XiQailHE - 1 �3N /
A
t4p� Desse Wok f t 0( 2__et-c,e4, L R,t. '-]J`. /
Fans Evaporative Cooler Hoods Electric Furnace/Ducts / Misce neous
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 �1*yry101-500M 501-1,000M
Heat Pumps(BTU) �(, d QA " v\
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 10,,,: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. A
SIGNATURE OF I / "' APPLICATION
OWNER OR .DATE