1984, 08-07 Permit App: 00001818 Heat Pumpw
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
/6/e
1 Owner's Name st)C (First) (M)
Department Use Only
�� �u�.� '¢--
Project No.
2 Project Address (Not Mai ing Address) Space Zip
3 ity/Communi y
State
Subdivision/Plat Name
4 Assessor Parcel No.
Lot
Block -
16 Cont/ ctor Firm Ne "
/' 7 S/' e' .
Street Address
/7..r,5�'i% ' S
t
7 C7
State
Phone
( ) - ,_ 5/t
18 Contact rerson
License No.
,y
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business
Address
9 Zip
City
State
Phone
( 1
15 Describe Work:
New Addition/Alteration E
Replace/Repair 'J
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:
Dryer(s):
l Range s):
Gas Log(s):
Wood Stove/
Solid Fuel:
Gas Water Heater(s):
11 UNIT HEATER(S): Wall Mount: Y N
Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. t.):
15 COMPRESSOR/HP: Less than 3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU:
100,001+ BTU:
18 TYPE FUEL SOURCE: Electric Gas E OiI ECoal „ Wood D Solar ❑
19 TYPE DISTRIBUTION: Forced Air ; Radiant E ; Heat Pump V
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 • - ting of a permit does not presume to give authority to
violate or cancel the provisions of any state • .cal laws regulating construction or the performance of
construction.
SIGNATURE OF4ita/APPLICATION �-/`
OWNER OR DATE�� 7��`