1984, 12-04 Permit App: 00003616 StoveF
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name Y (Last)///,((First)' / f M)
/t � I 1 e', / L 1 L 1 l Je /1 ,e Y \ (Al 1 7//7 el
Department Use Only
Project No.
2 Project Address (Not Mailin Address) \ Spaces Zip
3 City/Community
��//
.S/ o !1.1(4 :We
Stale
k /A sh
Subdivision/ Plat Name
4 Assesgbr Parcel No
Lot
Block
J
16 Contractor Firm Name
Street Address _.
17 Zip
I City
II
State
Phone
I )
18 Contact Person -
License No.
Phone If different than above
8 Owner/Agent (if different than 41 above)
Business
Address
9 Zip
City
State -
Phone
1
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)'
Hoods):
Duct(s) 1:
v
Miscellaneous'
10 APPLIANCE:
Dryer(s):
Range s):
Gas Log(s):
Wood Stove/
Solid Fuel:
Gas Water Heater(s).
11 UNITHEATER(S): Wall Mount: Y N
Floor Y 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 ; 011 0 ; Coa 0 ; Wood' 0 , Solar 0
19 TYPE DISTRIBUTION: Forced Alr 0 , Radiant 0 ; Heat Pump ID
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 DATE