1984, 10-10 Permit App: 00002767 Chimney, Woodstove1-
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owne ame/ (Last) (First) (M)
/3(Pa.& ' . 61nRi.
Department Use Only
Project No.
2 Project Address 7(Not Mailing Address)0,../(eS - Space
?gZip
34. adeV -
3 City/Compunity
(,3--X.0.--.....e
State
/✓%
Subdivisionn7Plat Name �1
ALet hnre AC/d
4 or Parcel No.
335V/ - 6 ik 3
Lo
3
Block
ii_
27677
16 Contractor Firm Name
Street Address
17 Zip
City
State
Phone
( )
18 Contact Person
License No.
Phone If different than above
8 Owner/Agent (if different than si above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work;
New 0 Addition/Alteration 0 Replace/ Repair 0
10 Applicant Name
Street Address
11 Zip
City
State
Phone
8 VENT: Fan(s):
Evap Cooler(s):
Hood(s):
Duct(s) 1:
Miscellaneous: l•
r.k /
10 APPLIANCE:
Dryer(s):
Range s):
Gas Log (s):
I Wood Stove/
1
Solid Fuel:
/
Gas Water Heater(s):
11 UNIT HEATER(S): Wall Mount: Y N
Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,00OCFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-SOOM:
500-1000M:
14 1003-1750M:
Other:
Pressure Vessel (cu. L):
15 COMPRESSOR/HP: Less than 3: 13-15:
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 0 ; Gas 0 ; 011 0 ; Coal 0 ; Wood Er Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; 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 OFA a APPLICATION
OWNER OR ((�. DATE /o—/a— err-