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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� � � ,,,s6.7,2ety 1 Project No. 2 Project Address of Mailing ddress) Space Zip ice-/- & . .(i 'o 3 City unit'r%, Statei Subdi�s(/on�nlPlat Name T �f 4 or Parcel No. Lot Block �/*Jy7 z� !1�/� 21-5/'/ 2-tif$ / 12 ,T�/ 16 Con or Fl Name Streetd 7 '�� ` /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 o W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M: LL o EL W 14 1000-1750M: Other: Pressure Vessel(cu.ft.): >- I- O 15 COMPRESSOR/HP: Less than 3: 3-15: 15-30: 30-50: 50+: Z Q 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