1987, 10-15 Permit App: 87003534 Wood StoveMECHANICAL PERMIT APPLICATION WORKSHEET 1i51
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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130 )(Soo
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, . L APPLICA
OWNER OR i��C�l- DATE
Project # 253 z/ -
`J,",J�i
Owner's Name Last First • MI
I Pia `l'-' C$1c -- 6 (. Ba2r— It
Project Address (Street Name & Number)
I1(l 0, we
City
`2D
State
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Subdivision/Plat Name
Assessors Parcel q085113 —QO I/
Lot
Block
Plat q
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor -
-Dr -Cates J .5-c
Add 053
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City / co
State w�
Zip 2n-—)
Phone C�C �/ /�
`i
Contact`%
`)t' c &ue._kJ
License#
(b cfr(-AGS 18 6 ti
Business Phone
S3 5-F7
Describe Work • ( )-)ccc-L_ Ck vtv !Jt( rota 0%((S I_ A-4ff S73vt S LT- p
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water hits
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
3-15HP
15-30HP
30 -501 -IP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10v,,;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 Q, . L APPLICA
OWNER OR i��C�l- DATE