1984, 08-31 Permit App: 00002106 Furnace MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name ast) (M) Department Use Only !f /Q�
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1 Project No.
2 Project Address of Mailing ddress) Space Zip
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3 City unit'r%, Statei Subdi�s(/on�nlPlat Name
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4 or Parcel No. Lot Block �/*Jy7 z� !1�/�
21-5/'/ 2-tif$ / 12 ,T�/
16 Con or Fl Name Streetd 7
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/7169Q1 /9/d/ .. .Zt '
17 i gx.), CCP)7 , State Phone- 2/ 6
18 Contact Person License No. Phone if different than above
8 Owner/Agent(If different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work:
New 0 Addition/Alteration 0 Replace/Repair
10n m$( ---e A Street Address
11 p City State Phone
( )
* *
8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1•E14is7 Miscellaneous:
10 APPLIANCE: Wood Stove/ P
Dryer(s): I 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
d 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
5
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W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
LL
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EL
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
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O 15 COMPRESSOR/HP: Less than 3: 3-15: 15-30: 30-50: 50+:
Z
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W 16 GAS PIPING SYSTEM:Number of outlets:
m
ZD 17 HEATING SYSTEM:1-100,000 BTU: 0 /`)/ 7 100,001+BTU:
18 TYPE FUEL SOURCE: Electric 0 ; Gas,X; Oil 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.
SIGNATUR0 — APPLICATION/ ,3 Q
OWNER 0' DATE U Y