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1986, 05-05 Permit App: 00010822 WoodstoveMECHANICAL PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND SpR 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 DATE fes_ i'‘ Project # 1.06,22 Owner's Name Last n First MI Project Address (Street Name & Number) ./'//9 6 City State �� �+d �C✓G/ Qy/ / %� /j Subd 1 on/Plat Name f/_ 1- --ter R e /_T' f CO t! 's VALLg-1e V 1 C:. Ass ors Parcel # /5S411 5 '7j Lot Block 1 Plat # Applicant Address City State Zip Phone Business Phone Contractor Address City State Zip Phone Contact License # Business Phone Describe Work Fans Evaporative Cooler 4 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 15-3011P 30-5OHP 50+HP Gas Piping 1-5 Outlets 6+ Outlets Gas Fired Heating System 1-100,000BTU 1Q,,,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 DATE fes_ i'‘