1984, 11-06 Permit App: 00003212 Fireplace Insert*
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M) Department Use Only
, ' 11 �
W ITI4ROL) e•Ap/41.� $. Project No.
2 Project Address (Not Mailing Address) Space Zip
gzj Co Em -r �zutit,.► 921z
3 City/Community
SPQt.ri
State
l�
Subdivl /Platyame
Utehrfd ,ive kir/ f'/(t7
4 Assessor Parcel No.
67512- — &6o I
Lot
Block
�2.._/2—
16 Contractor Firm Name
Street Address
17 Zip
City
State
Phone
( )
18 Contact Person
License No.
Phone If different than above
8 Owner/Agent (If different than #1 above)
Business Address
g Zip
City
State
Phone
( )
15 Describe Work:
New ❑ Addition/Alteration t'( Replace/Repair ❑
10 Applicant Name
tW IT R 0i,3 j ce4Ai•10/1-1.-<..
Street Address
13ZIc7 E. F/} lr2Vi(4.J
11 Zip
99 z.../ z,
City
...rPoKA,.iii_
State
C,),9-
Phone
(rof) pZ6-._.s--o3y
8 VENT: Fan(s):
Evap Cooler(s):
Hood(s):
Duct(s)1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
I Range s):
Gas Log(s):
oodSt f,/1cPLrj(...{
lid Fuel: ,N fg,,Lr
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: 1-100M:
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. t.):
15 COMPRESSOR/HP: Lessthan3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU: ✓
100,001 + BTU:
��(/Z,per /,'‘./ tif 6
18 TYPE FUEL SOURCE: Electric ❑ ; Gas 0 ; 011 0 ; Coal 0 ; Wood Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant ot; Heat Pump
1* Number of separate zones for any heating, A/C or air handling system.
1 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
ATE //MYAPPLICATION
ATE // / y