1985, 12-05 Permit App: 00009029 WoodstoveMECHANICAL PERMIT APPLICATION WORK$NEtT
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
V -n�� Dv,...1..
Project M
t n
Owner's Name First MI
10913 ds -%-N.
Project Address (Street Name & Number)
City�
S.
61/100....
Stat 11q ,%
Subdivision/Plat Name
Lot 1, t ,��` _ ot(ireLi
4 Block
-
vi
PlatCr-
R 1 o
s Parcel N
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
License #
Business Phone
Describe Work
Fans
Evaporative Cooler
t
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water }qtr.
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
t
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10u,;;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 cot -
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
DATE (1. S"-- S `�