1985, 10-01 Permit App: 00007799 Insert MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project# -,-7/7 G`j q
Ownr' Name L,ast First MI / t
Project Address(Street Name&Number)
/c75C 5 /�) t/Z
City State Subdivision/Plat Name
Lot Block Plat#
Assessorn�4 f ir1,
Applicant Address
//�G�/a-/-/ i)dtj 7675k-W LC-c 6-"/ ro 3 /�
City State Zip Phone
`37Z-,4": 4-/z------ ai/, *-'42. ) C.., $Zg - ..2--6-2.-
,
Business Phone
Cont orf _ 1l Address
/ ) (- L' t �- 't_'C�t�_C,
City State A Zip Phone
Contact License# Business Phone
/ascribe Work --
/ —(/17-- ��/ice-C—_ I ;/ t/e-- /anii5 C_ /-:"'7
�'� Fans Evaporative-Cooler Hoods Electric Furnace/Ducts Miscellaneous
Dryer Range Gas Log Gas Water Htr. Solid Fuel/Wood Stove
0-10,000 CFM 10,000+CFM
Air Handling Units
Refrigeration Systems/ 1-100M 101-500M 501-1,000M
Heat Pumps(BTU)
1,001-1750M Over 1750M
0-3HP 3-15HP 15-30H P 30-50H P 50+HP
Compressor
1-5 Outlets 6+Outlets
Gas Piping
1-100,000BTU 10.,.;00+BTU
Gas Fired Heating 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 n'� ^ i� _, '- APPLICATION ? �"
I
OWNER OR ' 9�� Y O--bA Ir i 1% ,. DATE / — ��