1984, 09-06 Permit App: 00002140 Wood Stove1 3 - to `i
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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
AiV 3 z .tii J , r
Project No.
/i�
2 Project Address (Not Mailing Address) Space Zip
N i914, gib; R4 cq,a l a.
3 City/Community
S per, 1‹,-.4_,,J4... kJ -0 114.
State
us.:
Subdivision/ Plat Name
4 Assessor Parcel No.
01S-43—ioO
Lot
Block
16 Contractor Firm Name
Street Address
17 Zip
City
State
Phone
( )
18 Contact Person
C11 AnIey. J 7f...-_. 1
License No.
Phone if different than above
C ,. ._,1 S
8 Owner/Agent (if different than #1 above)
Business Address
dpiicifk EM) �j_
9 Zip
sr1'a
i 1
City
`x{25/; .,k
State
(.L'V
Phone {�
( ) 7 e," -X 7'7/
15 Describe Work: �,cQ�
' i R. P1 N C -e. /.54e.-.,4.._ New ❑ Addition/Alteration ,' Replace/Repair ❑
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:Wood
Dryer(s):
Range s):
Gas Log(s):
Stove/
I Solid Fuel:
Gas Water Heater(s):
11 UNIT HEATER(S): Wall Mount: Y N
Floo : 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:
1
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 0 ; Oil ❑ ; Coal 0 ; Wood 0 ; 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 OF,
OWNER OR � \A
APPLICATION t
DATE 7"-- l