1985, 08-22 Permit App: 00007192 WoodstoveMECHANICAL 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. /*
v
SIGNATURE OF � / (� APPLICATION
OWNER OR U ��L 'L I� .DATE
Project #
Owner's Name ���rLast,
FFiir�st/ MI
Project Address (Street Name & Number)
PIP -0- -T /2 _ LU
City_ _ _ State— � Subdivision/ Plat Name �dok�
�r TU .A ^.��. C�L /`/ l� t�Ev 2cV !-icc�5 6'3rJ4?i-QeofU
Assessors Parcel #
Lot
Block
Plat #
Applicant
� J
Address
City
State Zip
�
Phon
Business Phone
Contractor
asp.-C�,��160p�xjc
Address
City
i�,
Sta�v�� Zip
_
G�'l J_7
Phone
Contact
License # _ /
Business . hone
Describe Work
Fans
Evaporative Cooler
Hoods
Electric Furnace/ Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/Wood Stove
Air Handling Units
0-10,000CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
03HP
3-15HP
15-30HP
30-50HP
50+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. /*
v
SIGNATURE OF � / (� APPLICATION
OWNER OR U ��L 'L I� .DATE