1984, 09-20 Permit App 00002448 Furnacef -
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MECHANICAL 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
Project No.
2
Project Address Mailing Address)
Space Zip
3
City/Community /�
42i
State SubdivI i%on�/Plat Name (/�/�-7�//(� ('''
CW � 4f 5,4 _i
4
Assessor Frarcel No.
L !G7 �'
Lot
Block//-
[
l;`/ �r-C-iQ
16
Contractor Firm/Na a
Street Address
17
Zip
City
State
Phone
18
Contact Person
License No.
Phone if different than above
8
Owner/Agent (if different than N1 above)
Business Address
9
Zip
City
State
Phone
15
Describe Work:
New ❑
Addition/Alteration ❑ Replace/Repair
10
Applicant Name
Street Address
11
Zip
City
State
Phone
8
VENT: Fan (a):
Evap Cooler(s):
Hood(s):
Duct(s)1: Miscellaneous:
10
APPLIANCE:
Dryer(s):
Range(s):
Gas Log(a):
Wood Stove/
Solid Fuel:
Gas Water Heater(s):
11
UNIT HEATER(S): Wall Mount: Y N
Floor: Y N
Suspended: Y N
12
AIRHANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13
REFRIGSYSTEM BTU: 1-100M:
100-50CM:
500-1000M:
14
1000-175OM:
Other:
Pressure Vessel (cu. ft.):
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 ✓ Gas ❑ Oil ❑ Coal ❑ Wood ❑ Solar ❑
19
TYPE DISTRIBUTION: Forced Air ❑
Radiant ❑ Heat Pump El
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 APPLICATION
OWNER O�U�iO/�� DATE