1985, 04-15 Permit App: 00004943 Wood Stove/ MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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 APPLICATION
OWNER OR DATE
Project # t
Owper's Name
Last First
MI
Project Address (Street Name & Number)
I v �a
ek
City
Statew
Subdiv' /Plat NamB i t S s, e N #1 /l
essors'Par v��� [ C n
CEJ: G�
Lot ' �
Block
lap
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Plat #
Applicant
Address
IN, /civ
h
City
State
Zip
Phone
�el —
0-9
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
License #
Business Phone
DescribeWork
Fans
Evaporative Cooler
Hoods
E16ctric Furnace/ Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water H!r.
Solid Fuel/Wood Stove
LCzi r SSG L
Air Handling Units
0-10,000CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1 000MM
1,001-1750M
Over 1750M
Compressor 1737-
3-15HP
15.30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
1W,,;W+BTU
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 APPLICATION
OWNER OR DATE