1986, 07-02 Permit App: 00011972 Furnace /ecu,
MECHANICAL PERMIT APPLICATION WORKSHEET 13K5
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) /{i �r, QQ ' (First) / _ (M) Department Use Only 1/477
t 5�-A-L._tl...,t-ti(_,L .Y- _jI Project No. f
2 Project Adde§s(Not Mailing Address) T � Space Zip
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• ./3 o-(2) . -- /^ — <— >r, '<
3 City/Community I State ' Subdivi lon/Plat Name�j
-...)...g3 c.-4. It,rti�. 1 r t.� Of-fOGC[—S
4 Assessor Pa .I No. Lot
4_ < <f- �i � 3 1. Block
1
16 Contractor Firm^Name 'Street Address
f.� - 1 , I
17 Zip City,-. State Phone
n r , 1 1
18 Contact Person / Licens_e No. Phone If different than above
8 Owner/AgenP different than N1 1ps bove) BusinAddress
f - _ %t- (_-v:----4--C>2A-- 1J .) C 1''- /u -
g Zip ' City State Phone
-
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15 Describe Work:
New 0 Addition/Alteration ❑ Replace/Repair
10 Applicant Namef Street Address
I V f ,
11 Zip City State Phone
( )
✓ 1 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):
Z 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
W -
a 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
7
0
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
LL
O
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
a_
>-
I- ,
O 15 COMPRESSOR/HP: Lessthan3: 13-15: 15-30: 30-50: 50+:
Z
Q-
W 16 GAS PIPING SYSTEM:Number of outlets:
m
D 17 HEATING SYSTEM:1-100,000 BTU: 100,001+ BTU:
Z rl ,. ^1-
18 TYPE FUEL SOURCE: Electric ❑ ; GasA; Oil 0 ; Coal 0 ; Wood 0 , Solar ❑
19 TYPE DISTRIBUTION: Forced Alr`/,� ; Radiant 0 ; Heat Pump
1 r 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. AL ,;..) i4M;
SIGNATURE OF f%�DNISIO •
!'�°ATti�f. INC
� �� �. '1"`'�'r � � APPLICATION
OWNER OR 'fr.� , DATE 7` a —
=PO .1�L
928.8.282