1986, 10-03 Permit App 00008020 Furnace, Wtr HtrMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project # 63C/,'0
Owner's Name --,----' Last Fi MI
,/,!/ G 4 �d r,
Project Address (Street Name & Number)
/ 2/ .�/-/ -74.e/ o .0
City ..
State
Subdivision/ Plat Name
Assessors Parcel # C7iiii )
Lot
Block
Plat #
A lira %
PP / ' 57 /�%t--) �-
Address
City a
State
Zip
Phone
Business Phone
Contractor
Address
City J
State
Zip
Phone
Contact
Licen e #
Business Phone
/escribe. l//i/f !/ ✓//�/7i1T l / GL/�`Z,--' �%1/ .‹.1,-1 77. /.%/J? %G f✓ C// •
Fans /
-Evaporative Cooler/
Hoods
Electr' urns ucts' .
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
0-3HP
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping y
1-5 Outlets /
!/
j
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 ooj_}ocal laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR
APPLICATION
DATE