1984, 10-03 Permit App: 00002645 FurnaceMECHANICAL PERMIT APPLICATION WORKSHEET 1 •
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner', Name /- (LaeG (First) (M)
Department Use Only
Project No.
2 Protect Address Not MailinglAdddrrle> Space Zi p
ee 3 1mC:is • 4 Fy so -3
3 City/Community
State
ti-513......zd
Subdivision/Plat Name
Assessor Parcel Na.
L t
I Block
16 Contractor Firm Name
CT Sim.,,. 9 .
t 0.k--
StrgitAddres
c- /art --..-.
17 1p �
qp
/ / /C co
t
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State
LI.Jo—_
Phone
( 1 9.1-ti-,PLl'-L
18 foment Person
License No.
4-/-0Ekr
61-1--ch
E.
Phone If different than above
8 Comer/ Agent Pl different than 01 above)
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Bt�pl
/
esAddress
r
9 LP dor
/ /`e'6 k
City (� ,,
State
�l o`
Phone
I 1
15 Describe work:
New > Addition/Alteration 0 Replace/Repalr ❑
///// ��`�`
10 Applicant Name
A CY-d #yp
Street Address
v
11 ZIP
City
State
Phone
( 1
8 VENT: Faille):
Evap Cool r(s):
Hood (s):
Duot(s) 1: x
Miscellaneous:
10 APPLIANCE:
DOWN):
I Range sl:
Gas Loph):
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: 10,0DOCFM or leu:
More than 10,000CFM:
13 REFRIG SYSTEM BTU: 1-100M:
103-500M:
,500.1000M:
14 10000750M:
Other:
Pressure Vessel (cu. LI:
15 COMPRESSOR/HP: Less than 3:
3-15:
15.30:
30-50:
50a:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU: Sf�j 67 /M-'
x'011
100.001+ BTU:
18 TYPE FUEL SOURCE: Electric C Gas ❑;
❑ ; Cos ❑ ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air pC Radiant ❑; Heat Pump
1' Number of separate zones for any heating, A/C or air handling system.
L. So
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 thls 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
OWNER OR
APPLICATION
DATE
,t