1985, 12-05 Permit App: 00009024 Wood StoveMECHANICAL PERMIT APPLICATION WORK$MEUT
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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 if�"
OWNER OR /1c+ct?�t 4201�'T`
APPLICATION
DATE/&/i5-
Project # , �T
% 7
Owner's Name Last First MI
P3 r`
CAt rr -I' :t>o u4L,} Sq-
Project Address (Street Name & Number)
L4tp15 3, P76U 6 -t -t rli6tf T.
City
LUSO _ 'lam
State
U.) fl -
Subdivision/Plat Name
(fl OtJ e -TATE'‘ ii 5
Assessors Parcel # , j� /2 — / (, /I l
Ci L�C L7L � 7
Lo
ri
Block
3
Plat #
Applicant
MR1mQ.s• ROOT 6,0 V",0
Address
rlY/s , Fit' -V i E»3
City
.Pb K,iN
State
u tor
Zip
9ct wia
Phone
92._&~-1-5 Z 3
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
License #
Business Phone
Describe Work
. N b Pcc.T (A) Cid 0 43/h P-Aii'tV LS 7DY& - ff? \J AT(... n rn !T
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,OOOM
1,001-1750M
Over 1750M
Compressor
0-3H P
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
1O OO+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 if�"
OWNER OR /1c+ct?�t 4201�'T`
APPLICATION
DATE/&/i5-