1984, 11-02 Permit App: 00003180 Wood Stove, Chimney•
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name.
j�(M
P//'' (Last) (First) ) Department Use Only
8I
Project No.
I u S-Eeveli t/
2 Project Address (Not Mailing Address) Space Zip
—1a)(0 Fa1RviEw 99ZI7.
3 City/CommunityState
5pokafnP,
WsaSa
Subdiivision/Plat Name
()iv u i Ave
4 -da- 71-r`,
4 Assessor Parcel No
i2 -Sr - 21.n %
Lot
Block
5/80
16 Contractor Firm Name
Street Address
17 Zip
City
State
Phone
( )
18 Contact Person
I License No.
Phone If different than above
8 Owner/Agent (11 different than PI above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work:
New ❑ Addition/Alteration
0 Replace/Repair 0
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
8 VENT: Fan(s).
Evap Cooler(s)
Hood
s).
Duct(s) 1.
y
Miscellaneous'
('H!AJrs/ai
10 APPLIANCE:
Dryer(s)'
Range s).
Gas Log(s):
Wood Stove/
Solid Fuel' /
4/
Gas Water Heater(s):
11 UNITHEATER(S): Wall Mount: Y N
Floor:
Y N
Suspended Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM.
13 REFRIG SYSTEM BTU: 1 -ICOM.
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. 14:
15 COMPRESSOR/HP: Less than 3:
3-15:
15-30:
30-50:
50+
16 GAS PIPING SYSTEM: Number of outlets
17 HEATING SYSTEM: 1-100,000 BTU' -
100,001+BTU:
/
18 TYPE FUEL SOURCE: Electric 0 , Gas 0 ; Oil 0 ; Coal ❑ ; Wood ta! Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; Heat Pump 0
1* Number of separate zones for any heating, A/C or air handling system.
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. / /gi.:/
SIGNATURE OF c /^ &4;0/,‘. APPLICATION J z f(1