1984, 10-15 Permit App: 00002899 Heat Pump MECHANICAL PERMIT APPLICATION WORKSHEET --',`' 6 c'4
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M) Department Use Only
i 4— G'N -- Project No.
2 Project Address(Not Mailing Address) Space /Zip
3 City/Community StateSubdi sion/Plat Name
>,)e)/-,A Z-Li • 4Le#4 2Ni PtPcl
4 Assessor Parcel No. , Lot Block
A- 2 -23o 2F),4 l
16 ntractor Firm Name ` Street Address
/ i`,1$4,),Yr4' /2 0 4•..9T//1//&- "Se /F;' C -,/iN/71T/ it/AiG , -,i y.�aC-' ,42/.SS./C4f
17 Zip City State Phone
��C�e;;;•R (.:_ ,.)/---)e)11',./Nom. l',--z . (<. )
18 Con ct Person License No. Phone if different than above
; / a°'
8 Owner/Agent(if different than#above) Business Address
9 Zip City State Phone
( )
15 Describe Work:
New ❑ Addition/Alteration ❑ Replace/Repair ❑
10 Applicant Name Street Address
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):
Z 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
W
2
a 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:
I.L.
0
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
>-
I--
0 15 COMPRESSOR/HP: Less than 3: 3-15: 15-30: 30-50; 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets:
ao
2
Z 17 HEATING SYSTEM:1-100,000 BTU: 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric T; Gas ❑ ; Oil 0 ; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air ❑ ; 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 f' -' APPLICATION
OWNER OR_ '..1.0../' .,.% C....,"7,-, ,:-.�L?',:d.-/ DATE / �01/
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