1985, 07-10 Permit App 00006371 Gas HeatingZ
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(First) (M)
Department Use Only
1 Owner's Name (Last)
/71—A/Z;0<Y 'Tee?/2_ y
Project No.
2 Project Address (Not Mailing Address) Space Zip
/
State
`/t
Subdivision/Plat Name
iLLE`tr /57` %Oa
4 Assessor Parcel No.
051// — 1r /
Lot
/
Block
16 ntractor Firm Name
Street Address
//
17 Zip
1��0
City
I ��,lld,,s-'.e1N E
State
/ ')4
Phone
(501) --:-.3.--- .... =
18 Co t Person
License No.
Phone if different than above
8 Owner/Agent (if different th 1 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work:
New f, Addition/Alteration ! ; Replace/Repair 'l
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
8 VENT: Fan(s):
Evap Cooler(s):
Hood(s):
f Duct(s)1:
Miscellaneous:
1-10 APPLIANCE:
Dryer (s):
Range s):
Gas Log(s):
Wood Stove/
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: 1-100M:
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. t.):
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: X
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas 7 ; Oil C ; Coal O ; Wood Solar
19 TYPE DISTRIBUTION: Forced Air C ; Radiant C , Heat Pump
1* Number of separate zones for any heating, A/C 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 F e / APPLICATION
0 6R���`� ���`�J �1 IlG��IU?��4/ DATE /0076-1