1987, 02-02 Permit App 87000260 Water HtrMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project # O
Owner's Name{ Last First M
' `/� ) j� I ,
Project Address (Street Name & Number)
lei 0Li
City
State
Subdiv' 'on / Plat Name
Assessors Parcel# 7 i S q f _ LI
Lot
Block ®
Plat #
Applicant
AddressBeyfri
City
State
Zip
Phone
Business Phone
Contractor
A) 0 X-C-4) C7 `I //4—/C— vC_
Address
s c 3 ( ` -i _Q-
City
Slb Kee i
State
(-(itt--
Zip
zr Z
Phone
Contact i `! — v
License #
/11r}e _o 4 17c �Z
Business Phone
Szcr 53 y Y97)`
Describe Work
E—Div,_-r e-- !'-._ l'9___e,tr-cr 'fh'c i 1 c/.s— ° r T )t 1 » e- /..:-r/ -
Fans
Evaporative Cooler
Hoods
Elehric Furnace/ Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/Wood Stove
Air Handling Units
0-10,000CFM
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
r
Gas Piping (/
1-5 Outlets
6 + Outlets
Gas Fired Heating System
1-100,000BTU
1a ,�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
• ' r yam/ r DATE CATION 2—