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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 `