1984, 07-31 Permit App: 00001504 Wood StoveZ
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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) (MI
H e r N 27D O N
Department Use Only f r (('),
Project No. 1 .] 1 J I
2 Project Address
�(Not -'}Mlailing Address)Space - / Zip
3 City/Community
r��� L
State
WA
Subdivision/Plat Name TY
Ud21 N I r •�-
4 Assess: Parcel No
r.A.5 CI -C1 - O`f o
Lot
I I G
Block
3
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
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
1 )
8 VENT: Fan(s):
Evap Cooler(s).
Hood (sr
Duct(s) 1:
Miscellaneous:
10 APPLIANCE;Wood
Dryer(s):
flange s):
Gas Log (s):
Stove/
Solid Fuel.
Gas Water Heater(s)'
11 UNIT HEATER(S): yyall Mount: Y N
Floo . V N
Suspended: Y N
12 AIR HANDLING: 10,000CFM 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 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 ; OII 0 ; Coal 0 ; Wood ❑ ; Solar 0
19 TYPE DISTRIBUTION: Forced Alt' 0 ; Radiant 0 ; Heat Pump
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.
SIGNATURE OF APPLICATION
OWNER OR dot), -lJo-J2-4 DATE