1984, 11-02 Permit App: 0003183 Furnace MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M) Department Use Only
e_ e j Zz / Project No.
2 Project Address(Not Mailing Address) Z Space Zip
3 City/Community State Subdivision/Plat Name
'` - � 01u -C11-y et,
4 Assessor Pel No. Lot Block
16 Contractor Firm Name Street Address
V //j e' — .y` -,,-XX'', ,f (-7//Jt&cel`_.-
17 Zip City / State Phone
q .-1e7 l ( ) fir- Lle 7(
18 Contact Person iceennse No. Phone if different than above
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work:
New ❑ Addition/Alteration ❑ Replace/Repair ❑
10 Applicant Name Street Address
11 Zip City State Phone
( )
* *
8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: Miscellaneous:
A-
10
10 APPLIANCE: I Wood Stove/
Dryer(s): Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
H 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:
U-
O --,
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
d
›-
I-
0 I-
0 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
Z
Q
CC
16 GAS PIPING SYSTEM:Number of outlets:
co
2
D 17 HEATING SYSTEM:1-100,000 BTU: 100,001+ BTU:
Z
18 TYPE FUEL SOURCE: Electric ❑ ; Gas ❑ ; Oil ❑ ; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant ❑ ; 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 •rovisions of any state of local, aws regulating construction or the performance of
construction.
SIGNATURE OF , #i�_� APPLICATION
OWNER OR !/ DATE /t/