1986, 09-06 Permit App: 00013132 Fireplace InsertMECHANICAL 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'""'�'APPLICATION q 16 J�g
OWNER OR .DATE
Protea #
Owner's Name
Last
First
MI
Project Address (Street Name & Number)
City
State
Subdivision/ Plat Name
SgZaMAZ
Assessorl Parcel #A
Applicant
Uq LL CU
i•'
2ee
Lot Block Plat k
Address
D-
City
State
Zip
Phone
Business Phone
Contractor
(/ p LL
G >°J
Address
. o . 8 -ox SSS&
City
State
Zip
Phone
Contact
License #
IJ A LL E F
/
Business Phone
-� O
Describe Work /uL Y-)
l b 8 U an aap L � n��2
v sY[ /�\jp�C
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
7707-1
1,001-1750M
Over 1750M
Compressor
0 3HP
3-15HP
15-IOHP
30-50HP
50+HP
Cas Piping
1-5 Outlets
6 + Outlets
Gas Fired Heating System
1-100'000BTU
10u,: 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'""'�'APPLICATION q 16 J�g
OWNER OR .DATE