1984, 11-30 Permit App: 00003570 Fireplace Insert1-
o.
-
a
O0
>
W
0
O
W
0
1-
0
ccZ
4
W
7
2
015tr9
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name(Last) civil(' (First) (M)
pa% NCiTW 111Y4 IPP/,4 _
vi
Department Use Only
Project No.
Sp ce Zip
2 Project Address (Not Mailin Address) l-
2003 Afe 571kPle Pc/ 1969/,6
3 City/Community
C�?/;�N, c�/—�v
State
r'S Ply tA7
WA
Subdivision/ Plat Name
4 Assessor Parcel No.
n75Yg1-05 3
Lot /
Block
16 Contractor Firm Name
Street Address
17 Zip
City
State
Phone
1 )
18 Contact Person
License No.
Phone if different than above
8 Owner/Agent (II different than 41 above)
Business Address
9 Zip
City
State
Phone
1 )
15 Describe Work:
New ❑ Addition/Alteration ❑ Replace/Repair 0
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( ) j2CP—ZoZj
8 VENT. Fan(s).
Evap Cooler(s).
Hood (s).
Duct(s) 1'
Miscellaneous:
10 APPLIANCE:
Dryer(s).
1 Range s):
Gas Log(s)'
Wood Stave/
Solid Fuel:
Gas Water Heater(s).
11 UNIT HEATER(S): Wall Mount: Y N
Floo : V N
Suspended Y N
12 AIR HANDLING: 10,000CFM or less:
More than 10,000CFM'
13 REFRIG SYSTEM BTU: 1-100M:
100-500M'
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu 5.):
15 COMPRESSOR/HP: Less than 3:
3-15:
15-30:
30-50:
50+
16 GAS PIPING SYSTEM: Number of out lets '
17 HEATING SYSTEM. 1-100,1100 BTU'
100,001+BTU:
18 TYPE FUEL SOURCE' Electric 0 ; Gas 0 ; Oil 0 , Coal 0 ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant ❑ ; Heat Pump
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 OF
APPLICATION
OWNER OR DATE