1986, 09-23 Permit App: 00013464 Wood StoveMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY,THOSE PARTS OF THE FORM YOU UNDERSTAN
Project # /g!/ o k/
KO�s-
Owner's Name Last First MI
SGtimph! Attic JR'
Project Address (Street Name & Number)
//Vina f, GEAe-ems
City
69o,ea-n�
State
CO A
Subdivision/Plat Name
Vette�tA7- tiv 8
Assessors Par IpOG6'- /�(`n
J
Lot Block -1 to
Platp SFR
Applicant
(.141-Lec, Cie e- z -P -PJ
Add ess
P 0 • 6ok rS�
City
�—-VPro4ae
State
W%
Zip
9 9 0 3 7
Phone
gat -.D -7j0
LI
Business Phone
ContractorAddress
Ula//el rr�lat-cam
1.74�0x .SS?
City /
Vera diafp_
State
(-tJT
Zip
99i.37
Phone
y.�-.a 7/0
Contact
License p
II 4u. et- / 7? 6 6 -
Business Phone
Describe Work
1 c� 4 Iran N 1� U y0 i (jam l (et u n� ui cJk� �..A x �i4�P,t� (i Lo-trAV,
z
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr
Solid Fuel/ Wooc Stove
Air Handling Unite
0-10,000CFM
10,000+ CFM
Refrigeration Systems!
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-311P
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10v,J00+BTU
I certify that the above information
visions of laws and ordinances
plied with whether specified
violate or cancel the provisions
construction.
SIGNATURE OF c I
OWNER OR G
herein
as submitted
governing this
or not. The
of any state
iJ
NJ -02--c 111
by me is true and correct and further, agree that all pro-
type of work, including inspection requirements, will be com-
granting of a permit does not presume to give authority to
of local laws regulating construction or the performance of
I
/1 �` it /t/`
_000 , cJ( tojJ%APPLiCATlON DATE `