1985, 09-05 Permit App: 00007270 Wood StoveMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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�' �Project
# ''
it
Owner's Name / Last First MI
Project Address (Street Name & Number)
/ ,/
/ Cf a'- / -/ /�i0 i.ci d1.1 i/iv F
City
Ck,:;,..-t
State
-0/3
Subdivson/Plat Name
412K bA0
Assessors Parcel # n
/`J ��i J i ._. o o
Lot /
Block
Plat #
ApplicantAddress
Pi L/ i " /`!c t' 1 ---
_
City /
State
Zi.'i/ �G't._-
Zip
/ , -" i �'
Phone /
l ---2 . - L7 / J
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
License #
Business Phone
Describe Work
»f( 11C
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
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 -151 -IP
15-30H P
30-50H P
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 ✓ r r i ‘V
APPLICATION i
DATE /_i