1987, 05-19 Permit App: 87001526 Rebuilt Chimney MECHANICAL PERMIT APPLICATION WORKSHEET
' PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project# ''-',/ i -2
Owner's Name Last First MI
t- �-tVf1C1,il K1(1.I' 0\4� Y'\
Project Address(Street Name&Number)
City State Subdivision/Plat Name �� �� ,
1-)C164,-VI ( - A 7e ► -KS
Assessors Parcel# 4 3 `� Lot Block Plat#
Applicant Address
_ ...
\C' • 1 ) lLtr 1"l ,ficrYI: v1 '�!t CIC'iLN vc-,
City , State Zip Phone
Business Phone
Contractor Address
�'f.�e.`�CA�G a I t 4�"� �, ti t;r'► I� + .„../ ��C �� G' � r�-�, _ �� ��;��.-i i t_ a' Cr.-,A c_cL,
City , State -, Phone
pc k et r>; t.,n c; r`: c' /
q / ; - '7&6= j2
Contact e License#/ Business Phone
Describe Work" 2 /75
l''-'e i(.'1 11- 1)141/.ic.- ( /irillity( � �� 00
Fans Evaporative Cooler J Hoods Electric Furnace/Ducts Miscellaneous
Dryer Range Gas Log Gas Water Htr. Solid Fuel/Wood Stove
010,000 CFM 10,000+CFM
Air Handling Units
Refrigeration Systems/ 1-100M 101-500M 5011,000M
Heat Pumps(BTU)
1,001-1750M Over 1750M
0-3HP 3-15HP 15-30H P 30-5OH P 50+HP
Compressor
1-5 Outlets 6+Outlets
Gas Piping
1-100,000BTU 10%,,.00+BTU
Gas Fired Heating System
IO( 0 R EL 0 k' co "rah( Apr-Li C A T-/r id0
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. )
i
SIGNATURE OF1' '_ �] ) 1 / APPLICATION �� -
OWNER OR ( �t.t!''L<t,��`�:�..�' ��_'} .DATE ;,�, i r' / /,