1984, 10-01 Permit App: 00002640 Furnace •
MECHANICAL PERMIT APPLICATION WORKSHEET . •
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND ,
1 Owner's Name (Last) (First) 2 (M) Department Use Only .—
>� a_$i ° rd,,_..._ („, -f . Project No. G 0
2 Project Address(Not Mailing ddresAf Space Zip
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3 City/Community State Subdivision/Plat Name
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4 Assess r Parc%I o. Lot Block
16 Contract7 Firm Name Stp st Address
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17 Zip City State Phone
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18 Contact Person License No. Phone If different than above
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8 Owner/Agent(if different than Al above) Business Address
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9 Zipr-._ ity _. State Phone
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15 Describe Work: YY
New/K Addition/Alteration 0 Replace/Repair 0
10 Applicant Name / Street Address
11 Zip City State Phone
( )
* , *
8 VENT: Fan(s): EvapCooler(s): Hood(s): Duct(s)1: Miscellaneous:
10 APPLIANCE: • Wood Stove/
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
2
a 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
5
0
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
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0
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+:
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W 16 GAS PIPING SYSTEM:Number of outlets: I
co
2
D 17 HEATING SYSTEM:1-100,000 BTU: �,
Q r-- 100,001+BTU:
Z 7.5/ C"'11 C" rl J
18 TYPE FUEL SOURCE: Electric 0 ; Gas, Oil ❑ ; Coal ❑ ; Wood ❑ ; Solar 0
19 TYPE DISTRIBUTION: Forced Air Radiant 0 ; Heat Pump
1* Number of separate zones for any heating, A/C or air handling system. 1 .so
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 OF
C"‘..._,Q APPLICATION
OWNER OR - -k.` ck --3-'4.--)4---4--t , DATE /'///i