1986, 04-11 Permit App 00010629 FurnaceMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Aa -es
C,.Ce d
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 �i APPLICATION .. /
OWNER OR_C �/�� DATE
Project # /
Owner's Name
Last
First.
i
MI
Project Address (Street Name & Number)
y
f
city
State /
Subdivision/Plat Name
Asse sors Parcel#
Lot
Block
Plat If
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor q '
Address !'
City
State
Zip
Phone
Contact
License #
Business Phone -7
Describe Work
Fans
Evaporative Cooler
Hoods
Eleciric Furnace/ Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/ Wood Stove
Air Handling Units
0-10,000 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3H P
3-15H P
15-30H P
30-50H P
50 + H P
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100'000BTU
10v,.-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 �i APPLICATION .. /
OWNER OR_C �/�� DATE
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