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1986, 11-03 Permit App: 00013969 Furnace, Piping MECHANICAL PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND Project# (%4')q Owner's Name t First MI //: `� Project Address(Street Name&Number) Z---'— c2/ / 77/ CJ12/2 City State � L Subdivision/Plat Name // 1 Assessors Parcel# 2-353V-(7Ls C/�/ i Lot Block Plat#. 38 Applicant f� Address 11 ` ce(.1,_( /4„A 07.... 76- ".34,44-tie, City State_ I Phone ipv, - (444,s/ 1 � '?L4 /f j - 6,r�!, Business Phone I, I' Contractor Address City State Zip Phone Contact LicBusiness Phone ensX /-/ /5-3 '.1/' X‘,`7 0 ,7a7- Describe Work 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 Compressor 0-3HP 3-15HP 15-30H P 30-50H P 50+HP 1-50utletsY 2 6+Outlets 2 Gas Piping J Gas Fired Heating System 1-100,000BTU / ,r, 1U, OO+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. ' SIGNATUR • ....-ort....-ortAPPLICATION ' OWNER OR .DATE /1 /-L-Vcr‘