1986, 09-25 Permit App: 00013297 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.
SIGNATURE OF
OWNER OR_
APPLICATION
DATE
Project #
Owner's NaZ Last First MI
L'4/U/=0 o (2 -
Project A ress Street Name R tuber)
State
Subdivision/ Plat Name
Assessors Parcel It
Lot
Block
Plat 8
Applicant
Address
City
State Zip
Phone
Uzi 31`7
Business Phone
Contractor
Address
City
State Zip
Phone
Contact
License N
Business Phone
Describe Work
Fans
Evaporative Cooler
Hoods
Electric Furnace/ Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/WI ood Stove
1
Air Handling Units
0-10,000 CFM
1 0,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101 -500M501
-11000M
1,001-1750M
Over 1750M
Compressor 777-1
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10.,:A0 + 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