1986, 08-28 Permit App: 00012937 Wood Stove- 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 (—i 1 I 1 APPLICATION /,•/
OWNER OR o- 1 KPit: LdA - ), • )Ct./1tC• ti-itF.i DATE `-d6
Project It i�/� G37
Owner's Name Last First MI
Pet /en.(-� e /L _l e re tj
Project Address (Street Name & Number)
E. /,'R3/,S lruthric.
City
S�?okGln
State
1 cJ A
Subdivi on/Plat Name ^___
_
&s -r Zip
tL nACRe-s
Assessors Parcel p 27 st/ t / di `5 s--7Lot
IL
1al
Black
iJi//�
Plat p
Applicant
VAIIg Fr'ep/Ae ew
Add
F.ess
I Ao s-
0. -3
City J State
VtrA-417/ wA
Zip
99x3.7
Phone
9a.D-37a0
-
Business Phone
Contractor/ {—
I/ ai ier 4 fl ) e
Address
O�.Phoni� . Qct T ,S S-S�
City
VOr dAle-'
Ste
CO (4
Zip
99637
e
9„,)).---)78 0
Contact
License it
-
(//}/L��LeAT /7766-
Business Phone
Describe((���� II'' �'�7��
DescribeWork XOec.. 380 ✓ARt e_di ct;tQ;& SoCWiI-i" cr,eQ. Sr•
VV
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Wate Htr.
Solid Fuel/Wood Stove
Air Handling Units
0-10,000 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,050M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10,,;.00+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 (—i 1 I 1 APPLICATION /,•/
OWNER OR o- 1 KPit: LdA - ), • )Ct./1tC• ti-itF.i DATE `-d6