1984, 06-29 Permit App 0000969 Relocate Gas MeterMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1
Owner's Name (Last)
(First)
(M)Department
Use my
Prolact No.
2
Project Ad cess (Not Mailing Address)
E �lyo 3 'E,
Space Zip
�i AO F�
3
City/Community
State
Subdivision/ Plat Name
o"P-ray Auc - Arm
4
Assessor Parcel No.
G
Lot
Block
16
Practor Firm Name
Street, Address _
17
Zip
G! ,ZU FS
City
State
C_,t_)C, _
Phone
60 ) a - -2-
18
tact Person
C�
Ll c nse No.
� N��j / 9 % �/�
Phone If different than above
.72 - Z
8
Ownerl Agent(it different than at above)
Business Address
9
Zip
City
State
Phone
1 )
15
Describe Work:
n l lt2p Add(tion/Alt tion Replace/Repair ❑
10
Applicant Name
Street Address
11
Zip
City
State
Phone
1 1
8
VENT: Fan(s):
Evap CooWill):
Hood (a):
Duct(a)1:
Miscellaneous:
10
APPLIANCE:
Dryer(a):
Range(s):
Gas Log(s):
Wood Stave/
Solid Fuel:
Gas Water Heater(s):
11
UNIT HEATER(S): Wali Mount: Y N
Floor: Y N
Suspended: Y N
12
AIRHANDLING: 10,000 CFM or lase:
More than 10,000 CFM:
13
REFRIGSYSTEM BTU: 1400M:
100-500M:
500-1Q90M:
i
14
1000-175OM:
Other:
Pressure Vessel (cu. H.):
15
COMPRESSOR/HP: Less than 3:
3-15:
15-30:
30-50:
50+:
16
GAS PIPING SYSTEM: Number of outlets:
17
HEATING SYSTEM: 1-100,000 BTU:
100,001 + BTU:
18
TYPE FUEL SOURCE: Electric C Gas
Oil ❑ Coal C Wood C Solar C
19
TYPE DISTRIBUTION: Forced Air C ;
Radiant C Heat Pump El
1' Number of separate zones for any heating, A/C or air handling systemV2,,-_). bc-')
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 APPLICATION _
OWNER OR �/ D,(1fD+�C/i % DATE a