1985, 12-20 Permit App: 00009206 FireplaceMECHANICAL 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 OCF%�
OWNER OR
APPLICATION
DATE
Project # (9 ,2,106,
Owner's Name t MI
deto--e...-----
Project Address (Street Name Number) z •/
" /J�bdivision/Plat
City
State
!r
SuName
s Parcel #
Lot
Block
Plat #
plicantAddress
,a14 w-41-7;_ei----Ir .c.7.,44......_,,,,..e_e 4.etz—,-;.....,„
,,../„..,A.?---;/\_.L......__e....Le..._.d___z.- ,_)
City
State
tea.
Zip
997
Phone
41_6-moo/7
-
Business Phone
Contract
Address
City "
--).-y4.2.---
tat
Zip
7 9 2-a 7
Phone
/f3 — /o / 2
License #
se
Business Phone
-- r Work ® !C_ti
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
r
IldFuel/Wod Stov
Air Handling Units
0-10,000CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10,,,,-,00+ 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 OCF%�
OWNER OR
APPLICATION
DATE