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1986, 10-14 Permit App: 00013590 Fireplace Insert
MECHANICAL 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 OF OWNER ORO - APPLICATIONI� DATE �i Project # / 3S f.V Owner's Name Last First MI e1e f er A 5 f e_r7 Project Address (Street Name & Number) 3z./ag S. 6r -/c r7 r7 City ^% �n P-- State �� Subdivision/ Plat Name A8s Parcel # Lot Block Plat # Applicant U A 1I el moireT / e eJ Address C /lv Gi © .5 -pr .0 cid, City Lie rkJAf-e,- State W A Zip 9 90 3 7 Phone j 9".? -.7/d Business Phone Contractor U a/ ley /= it ),AAeJ Address 1 _ it, G / 0 5ter�r�.// -G/ City / 11,er id 41-e tate /_,L) Zip f 90.3 Phone U 9 ... - 7f0 Contact License # Business Phone Describe Work ..<. i.4 irn t4.e0.^�'}4 ct oyt nilug Ck s (i,2 - t. (Jut,- G. Fans Evaporative COiler Moods Electric Furnace/Ducts Miscellaneous Dryer Range Gas Log Gas Water Htr. Solid Fuel /Wood Stove 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 30-5OHP 50+HP Gas Piping 1-5 Outiets 6+ Outlets Gas Fired Heating System 1-100,000BTU 10v,300+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 OF OWNER ORO - APPLICATIONI� DATE �i