1985, 07-15 Permit App 00006396 Gas PipingMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
I certify that the above information as submitted by me is
visions of laws and ordinances governing this type of work,
plied with whether specified herein or not. The granting of
violate or cancel the provisions of any state of local laws
construction.
SIGNATURE OF
OWNER OR_
true and correct and further, agree that all pro -
including inspection requirements, will be com-
a permit does not presume to give authority to
regulating construction or the performance of
APPLICATION
.DATE
Project
�L
Owner's Name Last%�F,�JstA
4
MI
Project Address (Street Name & Number
City
S Po K�N><
State
C,C�7T
s9div)rc isryionn/Plat Name
uAp A
DQ
Assessors Parcel N
37/'7
Lot
Black/
Plat N
Applican
l si_S S��PvICr< �0ti( Au
Address r
N 32ZI' YA S7
CI
MANE
State
���A
Zip
C�i2c'z
Phone
5o�i- 535 -22/5
Business Plane
Contractor
stfM xs APvI1eANT
Address
City
State
Zip
Phone
Contact
Lanae N
( `
Business Phone
Describe Work
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Hh.
Solid Fuel l Wood Stove
Air Handling Unita
0-10,000 CFM
10,000+ CFM
Refrigeration Systema/
Heat Pumps (BTU)
1-1001A
101-WOM
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
1530HP
30-50HP
50+HP
Gas Piping
1-50utlets
I
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10.,X0+BTU
I certify that the above information as submitted by me is
visions of laws and ordinances governing this type of work,
plied with whether specified herein or not. The granting of
violate or cancel the provisions of any state of local laws
construction.
SIGNATURE OF
OWNER OR_
true and correct and further, agree that all pro -
including inspection requirements, will be com-
a permit does not presume to give authority to
regulating construction or the performance of
APPLICATION
.DATE