1985, 01-08 Permit App: 00003868 Wood Stove1—
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name I (Last) (First) (M)
- C410Pba/i , irf,i r/ A
Department Use Only
Project No
2 Project Address (Not Mailing Address) Space Zip
E.. /1307 '"tele/,cit A* 99-010ro
3 City/Community
6 5-4M22---)td/1L
State
LV{q
Subdivslo
ln/Plat Name /'' j
P fr- W
r 4. ll'
4 Assessor Parce
0 q)k.1i-.— 1317
Lot
. 1-) ,
Block
r
16 Contractor Firm Name
Street Address
17 Zip
City
State
Phone
18 Contact Person
License No
t.
Phone if different than above
8 Owner/Agent Of different than 81 above)
Business
Address
9 Zip
City
State
Phone
( )
15 Describe Work:
New 0 Addition/Alteration 0
Replace/ Repair 0
10 Applicant Name
Street
Address -
11 Zip
City
State
Phone
( ) 90'7- 70/a
8 VENT' Fan(s)
Evap Cooler(s):
Heed (s):
Duct(s) 1:
Miscellaneous.
10 APPLIANCE.
Dryer(s): _
Range(s):
Gas Log(s):
Wood Shp el
Solid Fue • I
j
Gas Water Heater(s):
-11 UNIT HEATER(S): Wall Mount: Y N
Floor: , Y N
Suspended' Y N
12 AIR HANDLING: 10,000 CFM or less: r
More than 10,000CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M'
500-1000M:
14 1000-1750M.
Other:
Pressure Vessel (cu 1).
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 ❑ ; Oil 0 ; Coal 0 ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION. Forced Air 0 ; Radiant ❑ ; 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 777,t& k G -rt' �"CLvy/-c DATE /- Y Sr`S—