1985, 08-01 Permit App: 00006694 Mechanical Fixtures n
i-N MECHANICAL PERMIT APPLICATION WORKSHEET z •c' 0
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND =/, .-.? -''',-.
1 Owner's Name (Last) / . (First) (M) Department Use Only/4
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2 Project Address(Not Mailing Address) Space Zip
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3 City/Community StateSubdivision/Plat Name
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4 Ass or Parcel No. Lot Block
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16 Contractor Firm Name 4,---e-_ .
- ' Street 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#1 above) Business Address
9 Zip City State Phone
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• 15 Describe Work:
New ❑ Addition/Alteration ❑ Replace/Repair ❑
10 Applicant Name Street Address
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11 Zip City State Phone
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* . *
8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: Miscellaneous:
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10 APPLIANCE: Wood Stove/
• Dryer(s): I Range(s): Gas Log(s): / Solid Fuel: Gas Water Heater(s): // •
I-; 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
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n. 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
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W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
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a14 1000-1750M: Other: Pressure Vessel(Cu.ft.):
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15 COMPRESSOR/HP: Less than 3: 13-15: 15-30: 30-50: 50+:
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It 16 GAS PIPING SYSTEM:Number of outlets: /
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Z 17 HEATING SYSTEM:1-100,000 BTU: (Fe) d .�
C rT E"/4_
18 TYPE FUEL SOURCE: Electric ❑ ; Gas ; Oil 0 ; Coal 0 ; 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.
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 ,- �,1 • APPLICATION
OWNER OR /CL/ ALJJAz c.- DATE S"r"r -