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