1986, 04-25 Permit App 00010835 Heat PumpMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Mail
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. n
SIGNATURE OF X{I✓� APPLICATION
OWNER OR V DATE ✓ �(�
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Project # 166
D O 3S
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Owner's Name
Last t
2� vel
MI
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Project Address (Street Name & Number)
IS iSD_s Mero/couy-1
city
1% -v -A d -R I t
State
u-) A -
Subdivision/Plat Name
Assessors Parcel#
Lot Block
Plat#
Applicant
Address
City
State Zip
Phone
Business Phone
Centracto
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Address
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City V „//i LV�
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Stare (,1, u T/TE— 1% 1Zl
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Phone �0 _ 2 V!/
07`/D�7 )
Contact
License#
usinessj9hone
Describe Wok I�
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Fans
Evaporative Cooler
Ho s -
Electric Furnace/ Ducts
Miscellaneo
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/Wood Stove
Air Handling Units
010,000 CFM
10,000+ CFM
Refrigeration Systems/
eat Pumps (BTU) -2
CQ
1-10010
101-500M
501-1,OOOM
1,001-175010
Over 1750M
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,OOOBTU
10,,;,00+BTU
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. n
SIGNATURE OF X{I✓� APPLICATION
OWNER OR V DATE ✓ �(�