1986, 06-18 Permit App: 00011684 AC MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE,FORM YOU UNDERSTAND
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� 7il-A cOgD Project# if /_ee!
Owner' ame Last First MI ((�
i� 'e/f.)) �'1 C-) 9
Project Address(St Name&Number) �f
7,2 /Y' fof 7/
City State Subdivisi n/Plat Name
S'�'O0/1' Ge) 4We?Dc u4 PD PA 2 K A
Assessors Parcel# 6Vg s C�/l`gefo Lot 4,— Block Plat#
Applicant Address
City State Zip Phone
Business Phone
Contractor Address/2 _
,e , A/e—� 0/1/ 11—h ,,' 7 ,vi
City State I Zip Phone 5� i-N
ContactLicense# Business Phone -
,, rT41 a ��ait0 4-j 2v-�� :_,/--57.5—
Describe
- 7s-
Describe Work >�C /
Fans Evaporative Cooler Hoods Electric Furnace/Ducts Miscellaneous
Dryer Range Gas Log Gas Water Htr. Solid Fuel/Wood Stove
0-10,000CFM 10,000+CFM
Air Handling Units
Refrigeration Systems/ 1-100M /� 101-500M 501-1,000M
Heat Pumps(BTU) vim'
1,001-1750M Over 1750M
Compressor 0-3HP 3-15HP 15 30HP 30 50HP 50+HP
1-5 Outlets 6+Outlets
Gas Piping
Gas Fired Heating System 1-100,000BTU 10u,,,00+BTU
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/27,6%,":? i '/ �� APPLICATION Cd`��
OWNER OR .DATE �l