1985, 07-29 Permit App 00006852 Wtr Htr• 59 MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project # (5
Owner's Name Last - First MI
- ysfy 7i/32,
Project Address (Street Name & Number)
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City'==�
State
Subdivision/Plat Name
Assessors Parcel# /�� l
(fC �> ✓
Lot
Block
Plat #
Applican
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Add ess ,
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City
State
Zip �� n 7Phone
7
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact II
License #
iA"/2 a - i 1 / , - 1-9
Business Phone
rlbe Wo
;ve-(1,--,7,e7 ,...7-‘,24.ne.ice„,... 17,-.4p, 4:.,...z....ii.7.1,9,74.-- A.:,...,e. ,ezi_ ,A.e. d5r. 6,„,e,,m,„zel deb".
Fans
�'
Evaporative CoOler
Hoods
EI t Puce/Duh
Mi I nexus •
/LLB `T-50
Dryer
Range
Gas Log
Gas Water Htr. /ez
Solid Fuel/Wood Stove
Air Handling Units
0-10,000 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M Vo
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+ HP
Gas Piping
1-5Outlets 0
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10,,,;,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 Taws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR
APPLICATION
DATE —7— 2