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1985, 10-22 Permit 00008707 Insert
MECHANICAL PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND As bcro Project # C 7 Owner's Name nLast First MI Z-f4/2_, /Q .L—/ E3/4 /-* // Project Address (Street Name & Number) -7-/0 & - /\1072-./- City State Subdiv /Plat Name Assessors Parcel # - ©3e3 ciy Lot Block Plat # Applicant Address City State Zip Phone Business Phone Contractor Address City State Zip Phone Contact License # Business Phone Describe Work /4/S L/-4 r7 i;A/ CT- Gs ,(.c.7z/(_' //V / " Fans Evaporative Cooler Hoods Electric Furnace/Ducts Miscellaneous Dryer Range Gas Log Gas Water Her. Solid Fuel/Wood Stove Air Handling Units 0-10,000 CFM 10,000+ CFM Refrigeration Systems/ Heat Pumps (BTU) 1-100M 101-500M 501-1,000M 1,001-1750M Over 1750M Compressor 0-3HP 3-15HP 15-30HP 30-50HP 50+HP Gas Piping 1-5 outlets 6+ Outlets Gas Fired Heating System 1-100,000BTU 10v, 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. SIGNATURE OF OWNER OR / APPLICATION DATE //,