1984, 10-10 Permit App: 00002759 Wood StoveMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owne s N e (Last) (First) f (M)
•
Department Use Only/�)
,7 '�
enill/
�%!/
Protect No, ✓
�/ /.. t. L� �i %Q' C/
2 Project Address (Not Malfffffm�g A33333dre�ss�) / / Space
/z 95 'izo / e -in -1 r -P '
.Zip
3 City/Community
x
State
g/:A
Subdivision/ Plat Name
tvM,Nur'<pp
4 Ass
or Parcel No IYli
f -"BIZ- — !obi
Lot
8
Block
16 Contractor Firm Name
Street Address
17 Zip
Clty -
State
Phone
( )
18 Contact Person -
License No.
Phone 11 different than above
8 Owner/Agent Of different than PI above)
Business Address
9 Zip
City
State
Phone
15 Describe Worts
New ❑- Addition/Alteration 0 Replace/ Repair 0
10 Applicant Name
Street Address
11 Zip
City
State
Phone
8 VENT: Fan(s):
N_
Evap Cooler(s):
Hood (s):
Duct(s) 1:
Miscellaneous:
10 APPLIANCE:
Dryer(s).
Range(s):
Gas Log(s):
Wood Sto el
Solid Fuel' i
Gas Water Heater(s):
11 UNITHEATER(S)' Wall Mount V N
Roo : V N
Suspended. V N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-103M•
100-500M:
500-1000M: '
14 - 1000-1750M.
Other:
Pressure Vessel (cu. t.):
15 COMPRESSOR/HP: Less than 3: 13-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM. Number of outlets' -
17 HEATING SYSTEM:1-100,00013TU'
100,001+BTU'
18 TYPE FUEL SOURCE: Electric 0 ; Gas - 0 ; Oil 0 ; Coal 0 ; Wood 0 : Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; Heat Pump
1' Number of separate zones for any heating, A/C or air handling system.
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
APPLICATION
OWNER OR DATE