1986, 09-15 Permit App: 00013457 WoodstoveMECHANICAL 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
OWNER OR
APPLICATION G, � 5 4LDATE )
Project # /3z/5 7
J r�1�-
Owner's Name Last First MI
/22A L c A D LO
Project Address (Street Name 8. Number)
f, 3 5 / 7 Ler'C/fj
City
Okra -n �-
State
w A 99 a 0(,,
Subdivision/Plat Name
Assessor Parcel # g 35 /i -
•�Ji/7L 2/66
Lot
Block
Plat #
Applicant
VA-IIPAj rjr /40 C}
Address
, crc ,5--s- 3
_ j'g/�
City J
V nradar,°,
State
1.0A
Zip
9l'0-- 7
Phone
a- a -7k0
Business Phone
Contractor
UPll e.ti /jr liee-
Address
l'.O.%Ri. Ss --
City
U/'.)J-GQPI-e
tate Zip
1.A3 Pt _X903 7
Phone
q/ —; —7,4?d
Contact
License #
--)
Business Phone
Describe Work (4448.1--:, -p j) oCcYr L U" rtp_/Yi! Q�
., / 6 NT( WVIZI i (-t'„ p .t v . 0,-1 0....,
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
a
0-3HP
3-15HP
15-3OHP
30-50HP
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
OWNER OR
APPLICATION G, � 5 4LDATE )