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1984, 08-22 Permit App: 00001896 Wood Stove <k.. we. MECHANICAL PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND 1 Owner's Name (L t) ,(First (M) Department Use Only 16 S Project No. 2 Project Address(Not Mailing ddress) Space Zip _ 4-",' 73o ? 4• clQ2/2 3 City/Com ity State Subdi('),e /Plat Nape okl�he I &i,4 e rc/ 4 Ye Ade/ 4 Assessor Par I No. Lot 1 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(if different than 61 above) Business Address 9 Zip City State Phone ( ) 15 Describe Work: New ❑ Addition/Alteration ❑ Replace/Repair ❑ 10 Applicant Name Street Address 11 Zip City State Phone * 601 ) 62�-02/2 * . 8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: Miscellaneous: i 10 APPLIANCE: Wood Stove/ Dryer(s): I Range(s): Gas Log(s): Solid Fuel: l` Gas Water Heater(s): Z 11 UNITHEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N W a 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM: 5 0 W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500.1000M: LL 0 W 14 1000-1750M: Other: Pressure Vessel(cu.ft.): a r I- O 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+: Z Q Ail W 16 GAS PIPING SYSTEM:Number of outlets: CO 2 D 17 HEATING SYSTEM:1-100,000 BTU: 100,001+ BTU: 18 TYPE FUEL SOURCE: Electric ❑ ; Gas ❑ ; OII ❑ ; Coal ❑ ; Wood Solar ❑ 19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant 0 ; Heat Pump 0 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 / / 41 I APPLICATION OWNER OR _t_ -, . — DATE F/07.2/I? y