1985, 08-20 Permit App: 00007106 Furnace . MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last)
?jilt) J.M) Department Us Opl
C A-,�C J Project No. /Old
2 Project Address(Not Mailing Address)j. Space Zip
',/ i,? 9'�—. 9737
3 City/Co,munit ' State ) Subdivision/Plat Name
i �_1 ^_.Cle- —e---- a/'(-' (l/2_%4 C 1(e S oti t3 p i :./ t >'c
4 A s' sor Parcel No. Lot Block 0.s )(, «_
16 Contractor irmame 1 Str t Address
17 Zip City State Phone
rjet i o1 S/'d > ) u) (-f-7-1 ) ‘9.---,3V— jT., _
18 Cont Per on License No. Phone if different than above
..s, 1
8 Owner/Agent(if different an#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work:
1 New ❑ Addition/Alteration ❑ Replace/Repair ❑
10 Applicant Name Street Address
11 Zip City State Phone
( )
r : *
8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: Miscellaneous:
10 APPLIANCE: Wood Stove/
• I
Dryer(s): Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
I—; 11 UNIT HEATER(S): Wall Mount: V N Floor: Y N Suspended: Y N
Z;
W.
aa. 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
0�
0
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
U-
0
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
Ct.
>I—
® 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets:
M
2
Z 17 HEATING SYSTEM:1-100,000 BTU: , //''46.../�j/ 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas /I - Oil (❑ ;; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant ❑ ; Heat Pump CI
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.
SIGNATURE OF01 / 21, APPLICATION —
OWNER OR %" I
/ " ( -z'� %fit DATE � /