1985, 01-14 Permit App: 00003913 Wood StoveMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner me (Last) ,(First) (
Department Use Only
0k,a>n/` YAi)
ProjectNo.
2 Project Address (Not Mailing Address •
a in7i9 MaliSpace Zip
3 City/Community
C )'
State
.
Subdivisio /Plat Name
zrb'z.CNi:Y
4 Assessor arcel No.
Lot
I Block
16 Contractor Firm Name
Street Address
17 Zip
City
State
Phone
( )
18 Contact Person
License No
Phone If different than above
8 Owner/Agent (1 different than 41 above) -
Business Address
9 Zip
City
State
Phone
)
15 Describe Work:
New ❑ Addition/Alteration
❑ Replace/Repair 0
10 Applicant Name \/ 77
'`e-i� L %a- -h0/ll
Street Address
11 Zip
9 9 )_OLP
City
ap?.
State
1,001-31t7
Phone
( y - 7/-)R - 3'63 i
8 VENT. Fan(s).
Evap Cooler(s).
Hood(s).
Duct(s) 1.
Miscellaneous.
10 APPLIANCE:
Dryer(s):
Ranges)'
Gas Log(s):
Wood Stove/
Solid Fuel
Gas Water Heater(s).
11 UNITHEATER(S): Wall Mount' Y N
Floor. Y N
Suspended: Y N
12 AIR HANDLING: 10,000CFM or less'
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-103M:
100-500M
500-1000M:
14 1000-1750M
Other:
Pressure Vessel (cu. t.):
15 COMPRESSOR/HP. Less than 3:
3-15:
15-30:
30-50:
50+•
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU:
100,001 + BTU
11 �/
18 TYPE FUEL SOURCE' Electric 0 ; Gas 0 ; Od 0 ; Coal 0 ; Wood . • Solar 0
/�'
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant Heat Pump
1* Number of separate zones for any heating, A/C or air handling system.
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
OWNER OR DATE