1987, 03-27 Permit App: 87000818 Furnace, Piping •
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MECHANICAL PERMIT APPLICATION WORKSHEET ' '� ,�
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
81 y las SFR
1 Owner's Name (Last)_ (First) (M) Department Use Only
40-S� r/qA" - y Project No. �-8Ie
2 Project Address(Not Mailing Address) � t ,oace Zip
9 /G/7 T
3 City/ mmunity State I Subdivision/Plat Name
4 Assessor Parcel No. Lot Block
265443 -1512. ig___ ,S`
16 Con tor Firm Name Street ddress -- .
17 Zip City State Phone
18 Contact Person / License No. Phone if different than above
B Owner/Agent(if different than M1 above) I Business Address
1
9 Zip City State Phone
( )
15 Describe Work:
New 0 Addition/Alteration 0 Replace/Repair 0
10 Applicant Name Street Address
1
11 Zip City State Phone
( )
* , *
8 VENT: Fan(s): E4ap Cooler(s): Hood(s): Duct(s)1: Miscellaneous:
10 APPLIANCE: Wood Stove/
Dryer(s): 1 Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
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Z' 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
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d 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
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W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
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W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
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O 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: I 30-50: 50+:
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16 GAS PIPING SYSTEM:Numbf outlets: (f) ,z5-4.2 4
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O• 17 HEATING SYSTEM:1-100,000 BTU: 7 --------- 100,001+ BTU:
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18 TYPE FUEL SOURCE: Electric 0 ; Gas 0 ; OII 0 ; Coal 0 ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; Heat Pump 0
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. r
SIGNATURE OF EriAPPLICATION /,
OWNER OR Ei ) �,eft. DATE ` �` /
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