1985, 03-28 Permit App: 00004681 Woodstove, Chimneyy MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
S Fe
/Coo 6
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 Q APPLICATION
OWNER OR DATE
Project « .41 /
Owner's Name Last
Lk C_ k I c
First
POLLJ
MI
Project Address (Street Name & Number)
12 sus 1. a K0 ra,,
0v //0
City1
O 01�U V11
Statae
w
Subdivision /Plat Name 1
+/i 1( �%I r�Tca, � SPS
Assessors Parcel NL�1 D
Lot
Block _
7
Plat M
Applicant
Address
City
State
Zip
Phone
9 2y-9zZ,6
Business Phone
y �-aZz
Contractor
Address
City
State
7 Zip
Phone
Contact
License #Business
Phone
Describe Walk eJt!�OC�S�CJV,✓
Hosowr
f ow nre
Fans
Evaporative Cooler
Hoods
Ela&rlcFurnace/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)
1-1100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
77�
3-15HP
77P
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
IW,Z.W+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 Q APPLICATION
OWNER OR DATE