1986, 10-10 Permit App: 00013539 Wood StoveMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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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 OR
CL.
Cc t -C7
APPLICATION
DATE / o -
/;
Project B /B53y
Owners Name Last /I First MI
C.Ii6Yc.Ci lJ�e�p &`
Project Address (Street Name & Number O
t..3 7—° t2 LA-LA-1CP- e.>4,,$)
City
bCpr.s
State
1N
Subdivision/Plat Name
T
(lock `� LI
Assessors Parcel 0 tJ1S 03 1/
1
Lot
Plat ` R./
064.9
Applicant rr
liE>Y/
9 n` .-fyn'-r-r
Address
(,j'yo. L 1464,.:.? -4- 1.-r:
City
i. oli-,ccs
State
tli IA-
Zip
ci`i 2-12-
Phone
(Scl>q) 92-4 • 27 I -4 -
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
License 0
Business Phone
Describe Work
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/Wood Stove
Air Handling Units
0-10,000 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3 -151 -IP
15-3OHP
30-50HP
50+HP
Gas Piping3
1-5 Cutlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
q
10.,,L00+BTU
('4'WU—Ou at
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 OR
CL.
Cc t -C7
APPLICATION
DATE / o -