1985, 12-02 Permit App: 00008941 Wood StoveMECHANICAL PERMIT APPLICATION WORK$WUT
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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Project# �7-� ri,e/
Owner's Name _Last First MI
Project Address (Street Name & Number
e 7a3 M/7 1 /(/ g 2/2
City
Se'6�oryr-
State
w / -7
Subdivision! Plat Name
H4 -2R. nl To nt %d 1 -hie � /
Assessors Parcel #
,651/4/- /1178
Lot Block
f 2
Plat #
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
Licensee
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
3-15HP
15-30HP
30-SOHP
50+HP
Gas Piping
1-5 outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10..0:00+87U
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
--5-
APPLICATION /1 2 bis
DATE