1984, 11-28 Permit App: 00003568 Gas Log •
•
.
MECHANICAL PERMIT APPLICATION WORKSHEET
NJPLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
%,j 1 Owner's Name Last)` (Fir ) A (M) Department Use Only _
>/� Project No. _
2 Project Address(Not Mailing Address) / I/ '///��� Space Zip
• ryfr , i f/ �— T/J/
! ':M `_ / /6
3 City/Community State Subdivision/Plat Name
i 16
4 Assessor Parcel No. r Lot Block J
Zz51 140z ( 3 3C, l
16 Contractor irT Ne e% / Street Address
7 Zip CiL✓ �� ,� State Phone
t 18 Contact Person License No. Phone if different than above
-/ NA, Owner/Agent(if different than#1 above) Business Address
y - g Zip City State Phone
'4 ( )
15 Describe Work:
New ❑ Addition/Alteration ❑ Replace/Repair ❑
' i 10 Applicant Name Street Address
11`'
1 Zip City State Phone
( )
* . *
8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: Miscellaneous:
10 APPLIANCE: Wood Stove/
Dryer(s): 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
Z
W
2
a 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
a
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
LL
0
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
a
›-
I-•0 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
Z
Q
CC
W 16 GAS PIPING SYSTEM:Number of outlets: -
m v/ 5
-
Z 17 HEATING SYSTEM:1-100,000 BTU: 100,001+B U:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas R-1' Oil ❑ ; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant ❑ ; Heat Pump El
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 APPLICATION (/
OWNER OR �" '—;,. –,-eZ .C_i�c r' DATE 7//2,-V K