1986, 06-06 Permit App: 00011679 AC ,
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
' Project# //&
79
Owner's Name Las ;log)._ MI
Project Address(Street Name 8 N er)
40. 'AS - /4 94, CI) 6--6-12-2,0-44-4Q-
Ci , StateSubdivision/Plat Name
W4
q `laoh LyAica
Asses Parcel# 2/5-li —Po V- Lot tit Block / Plat#
Applicant Address SFS
City State Zip Phone
Business Phone
Contr ctor Address
r / ?/D LL
City State ip Phone
Contac ... ..(e. License# Business Phone
r+mou�NE - X93 Ni ,5ArVkt
Describe Wore, I }►
O-1/1 — r.,,?-21:- /b--1-1_ eek-e0441-4-0 a4-4--e-d--t-c-id6wi-e-4.,
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
r �'?J RefrigeratioHeat Pumpsn(BTU)ms�\�' �p 1-100M 101-500M 501-1,000M
l 1,001-1750M Over 1750M
Compressor
0-3HP 3-15HP 15-30H P 30-5GH P 50+H P
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.
SIGNATURE OF ( ,,, /�
APPLICATION
OWNER OR �"�� �` DATE (0---- 4 — g4