1985, 03-11 Permit App 00004482 Furnaceks
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name AVib 74/e_ ,J (M
V
Department Use Only
Pralact No.
2 Project Address (Not Mailing Address)/ ' e I ^ Space Zip
3 Cityl rommunit
Slat Subdiv Ion l Pial Name
V I ecu 5d
4 Assessor WrCel No.
Lot
Block
16 GonX
Firm Name -
Street Address
17 Zip
��
ty
jk�
State
w,a
Phone
18 Contact Person
License No.
E -15IN1
Phone If different than above
8 Owner/ Agent (if different than a1 above)
Business Address
9 Zip
City
State
Phone
( 1
15 Describe Work:
New ❑ Addition /Alteration ❑ Replace/ Repair ❑
10 Applicant Name
Street Address
11 Zip
__7E
City
State
Phone
I I
8 VENT: Fan (a):
Cooler(s):
Hood(s): Duct(a)1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
Range(s):
Gas Log (a):
Wood Stove/
Sol Id Fuel:
Gas Water Haster(a):
11 UNIT HEATER(S): Wall Mount: Y N
Floor: Y N Suspended: Y N
12 AIR HANDLI NG: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-50OM:
503-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. ft.):
15 COMPRESSORIHP: Leas than 3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Numberof outlets:
HEATINGSYSTEM: 1-1f X/f}, .1 .i
if �Gaass
100,001+BTU:
TYPE FUEL SOURCE: E rlc O 61—; Oil ❑ Coal ❑ 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. __Q
SIGNATURE OF z > � J�j -N iAPPLICATION
OWNER OR CTlll GGG 1. 'vC- .DATE '- —7l /SEs