1986, 04-18 Permit App: 00010574 Wood Stove5 3-2-1T(
MECHANICAL PERMIT APPLICATION WORKSHEET
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
OWNER OR_
APPLICATION
.DATE
Project N
Owner's Name
Last First
_ MI
Project Address (Street Name & Number)
City
S o A N
State
Subdivision/ Plat Name
o
Assessors Parcel #
0&513 — 2.qc)-3
Lot
Block
Plat N
Applicant
_T
Address
City
tate Zip
Phone
Business Phone
Contractor
Address
City
State Zip
Phone
Contact
License N
Business Phone
Describe Work
Fans
Evaporative Cooler
Hoods
Electric Furnace I Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/ Wood Stove
Air Handling Units
0-10,000CFM _T
0,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501 1000M
1,001-1750M
Over 1750M
Compressor
0 3HP
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
1 W,,;W + 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