1984, 11-20 Permit App: 00003443 Wood StoveF
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's NameD (I-astl (F' I/ / (M
Department Use Only
L t / %
/� Q / /"j` �f
Project No
2 Project Address (Not Mailing Address) Space Zip
/ 4�6 06-' inet1 h %9,a7l G
3 City/Community \\
$ fokavie (JeraJ4/e J
State• ,
(, .
SubdivisionIFlat Name
PO
4 Assessor P cel No
1`f'S43 — 2' Ic
Lo
J
Block
16 Contractor Firm Name
Owkjer •-4.-,5A•74l
Street Address
17 Zip
City
State
Phone
(elli) gay'—o(6 e/
Phone if different than above
18 Contact Person
License No.
8 Owner/Agent Of different than p1 above)
Business
Address
9 Zip
City
State
Phone
( )
15 Describe Work.
New AY Addition/Alteration
0
Replace/Repair 0
10 Applicant Name
Street
Address
11 Zip
City
State
Phone
8 VENT. Fan(s):
Evap Cooler(s):
Hood a)•
Duct(s) 1:
Miscellaneous'
10 APPLIANCE:
Dryer(sr
Range s)'
e/
Gas Water Heater(s).
Gas Log(s): C5c.olldRieit.
11 UNIT HEATER(S). Wall Mount: Y N
Floor Y N
Suspended: Y N
12 AIR HANDLING. 10,000 CFM or less:
More than 10,000CFM:
13 REFRIG SYSTEM BTU: 1-100M:
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: 1-100,000BTU:
100,001+BTU'
18 TYPE FUEL SOURCE. Electric 0 , Gas 0 ; Oil 0 ; Coal 0 , Wood A-. Solar ❑
19 TYPE DISTRIBUTION: Forced Air ❑ ; 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
OWNER OR
i�� APPLICATION //
? DATE