1984, 09-18 Permit App: 00002347 Wood Stove*
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M)
Department Use Only
A4 / HA L i G s5U :S ft N 1,4 .
Project No.
2 Project Address (Not Mailing Address) Space Zip
r_ ego// cfjL 99z./ z
3 City/Community
s l'®t*-e."-/,ie•.
State
1,(7/.
Subdivision/ Plat Name
, esce�feis Add
4 Assessor Parcel No.
/F61/7 — 0627
Lot
1 l
Block
16 Contractor Firm Name
Street Address
17 Zip
I City
State
Phone
( )
18 Contact Person
License No.
Phone if different than above
moo..
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work:
New ❑ 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:
10 APPLIANCE:
Dryer(s):
Range s):
Gas Log (2):
Wood Stove/
Solid Fuel: }
Gas Water Heater(s):
11 UNIT HEATER(S): Wall Mount: Y N
Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. t.):
15 COMPRESSOR/HP: Lessthan3:
3-15:
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 ❑ ; Oil 0 ; Coal ❑ ; Wood e"...,--
7 Solar ❑
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; Heat Pump CI
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 O- ' APPLICATION
OWNER OR `/�' ��L� DATE r�g�¢