1984, 10-12 Permit App 00002819 Damper, Wtr HtrMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1
Owner's Name (Last)
- (First)
(M)
Department Use Only
No.
CM
G -t
Project
2
Project Address (Not Mailing Address)
_
Space Zip
10Z 2 !; I c
3
City/Community
7
State
t
Subdivision /Plat Name
W GL
L�YtV
4
Assessor Parcel No. 1
Lot _
Block
1;4A',4 — f
16
Contractor Firm Name
—�
Street Adtlress
z7h Id��l'ia��cc
�1 %ca
17
Zip
q7— 6
City
s�,� l> e
State
mat
Phone
Is-? ) y
1B
Contact Person
License No.
Phone if different than above
8
Owner/Agent(if different than 01 above)
Business Address
g
Zip
City
State
Phone
1 )
15
Describe Work:
New
❑ Addition /Alteration ❑ Replace/Repair ❑
10
Applicant Name t
Street Address
6-" 1
/G/ Z}-
11
Zip
Ze,(.
City
I
State
6tll'�
Phone
(sr�) y2Z-zz 9
6
VENT: Fan(s):
Evap Cooler(s):
Hood(s):
Duct(s)1:
Miscellaneous�IG�r
LL
10
APPLIANCE:
Woad Stove/
Dryer(s):
Range(s):
Gas Log(s):
Solid Fuel:
Gas Water Heater(s):
11
UNIT HEATER(S): Wall Mount: Y
N
Floor: Y N
Suspended: Y N
12
AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13
REFRIG SYSTEM BTU: 1 -100th:
100 -500th:
500-1000M:
14
1000-175OM:
Other
Pressure Vessel (cu. ft.):
15
COMPRESSORIHP: Less than 3:
3-15:
15-30:
30-50:
50+:
16
GAS PIPING SYSTEM: Number of outlets:
17
HEATING SYSTEM: 1-100,000 BTU:
%!� /7
Sau�f�(
100,001+ BTU:
L -t �ls<7
LLL---;(((
!Coal
18
TYPE FUEL SOURCE: Electric ❑ Gas Oil
13L✓
❑ Wood ❑ Solar ❑
19
TYPE DISTRIBUTION:
Forced Air ❑ Radiant ❑ Heat Pump El
1' Number of separate zones for any heating, AIC 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
OWNER OR_
APPLICATION
DATE