1986, 10-15 Permit App: 00013648 Insert MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project#
Owner's Name Last First MI
ntZ0,4 6ci L.
Project Address(Street Name&Number)
(
City_ State Subdivision/Plat Name
e
Assessors Parcel# Lot Block Plat#
%, Applicant Address
City State Zip Phone
(2S -. Z '
Business Phone
Contractor Address
City State Zip Phone
Contact License# Business Phone
Describe Work
V1
(J/
r
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
Refrigeration Systems/ 1-100M 101-500M 501-1,000M
Heat Pumps(BTU)
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 10u,;.: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