1988, 09-27 Permit App: 88003103 Pellet StoveIt
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
3\O
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
APPLICATION
DATE _i ��
Project ft
Owner's Name<'� Last First MI
JfeY?So ,C S--c.v z
Protect Address (Street Name & Number
/U. 9-C) 7 (Le n ff. r Rd •
City I
Jpo,C ti ne
State
£JA
Subdivision/Plat Name
Assessors Parcel 0
Lot
Block
Plato
Applicant( --,Add
feve SVenrsoh
ess
Av.. ayo9 ee.n 71ei.r RI.
Cityc,
J 0O kO r;2-
State
6°4
Zip
t9a l z
Phone
Cia 51- — -7 3 6 6
Business Phone
67.27- 5-7, 3 /
Contract /_lHall IA 1'nine % .J ti/
Add J. /30 Y Rai
a/City
City J‘?
State /
(Am
Zlp m
Phone $L
Contact '
License 0
TvPNAc 1 RUl �
Business Phone
r,
Describe Work ,
Tnv-Ja /! p?t//tt el ve_
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Wate 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
3-15HP
15 -301 -IP
30-5OHP
504 -HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10.,,:.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
APPLICATION
DATE _i ��