1988, 01-12 Permit App: 88000060 Furnace, Piping i ,. :r
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MECHANICAL PERMIT APPLICATION WORKSHEET
I PLEASE PRINT AND COMPLETE ONLy.THOSE PARTS,OF.THE FORM YOU UNDERSTAND
1 Owner's Name (Last) . (First)/� (M) Department Use Only
I Name ,
4 L 4 i 4T/e,/7i `Project No. 13>`S-ts,23
2 Project Address(Not Mailing Address) �.�,, -.Space Zip
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3 City/Community State _ Subdivision/Plat Name
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4 Assessor Parcel No. Lot Block
16 Contractor Firm Name Street Address A
�� �4,-..� l-e 2-�,cte` ▪ -: , SIV/i. /
17 Zip CState Phone
T a 4' YJ � -e._ //21-`-- . (
. ) 9, e----89, e----8: -,,,2_18 Contact Person /LicenseN�.
Phone If different than above
8 Owner/Agent(If different than#1 above) I• Business Address
9 Zip City State Phone •
15 Describe Work:
New XI - Addition/Alteration ❑ Replace/Repair. 0
10 Applicant Name -— Street Address
11 Zip City State _i s Phone
* *
8 VENT: Fan(s): Evap Cooler(s): Hood(s): ", Duct(s)1: Miscellaneous:
10 APPLIANCE: I Wood Stove/
Dryer(s): Range(s): - Gas Log(s): Solid Fuel: Gas Water Heater(s):
F— 11 UNIT HEATER(S): Wall Mount: Y N Floor: V N Suspended: Y N
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a 12 AIR HANDLING: .`10,000 CFM or less: More than 10,000 CFM:
0
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:.
W
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W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
Q.
O 15 COMPRESSOR/HP: Lessthan3: 3-15: - 15-30: 30-50: 50+:
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u1� 16 GAS PIPING SYSTEM:Number of outlets: / (1; _-_.'21 ' b
m 1
O 17 HEATING SYSTEM:1-100,000 BTU: I 1 J 100,001+BTU: ,.
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18 TYPE FUEL SOURCE: Electric 0 ; Gas >4 Oil 0 ; Coal ❑ Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Alr 0 ; Radiant 0 ; Heat Pump
1* Number of separate zones for any heating, A/C or air handling system.
I certify that the above in orrnation 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 ':``r APPLICATION
OWNER OR �. DATE / /a Sy
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