1984, 10-04 Permit App: 00002748 Insert*
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) �,Fj1rst) (M)
Davern J lm
Department Use Only
Project No.
2 Project Address (Not Mailing Address) Space Zip
E. 7106 Marietta 99212
3 City/Community
Spokane
State
WA
Subdivision /Pme at ,
T% �Y '
4 Assessor Parcel No.
/253/-6 02
Lot
I Block
�� 1
16 Contractor Firm Name
Valley Fireplace
Street Address
E. 16610 Sprague
17 Zip
99037
City
Veradale
State
WA
Phone
( 509 922-2780
18 Contact Person
License No.
VALLEF 177CG
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business Address
g Zip
City
State
Phone
(
15 Describe Work: Installation of Convector
New ❑ Addition/Alteration
Supreme Insert
❑ Replace/Repair ❑
10 Applicant Name
Street Address
11 Zip
City
State
Phone
(
8 VENT: Fan(s):
Evap Cooler (s):
Hood
s):
Duct(s)1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
I Range s):
Gas Log(s):
Wood Stove/
Solid Fuel: 1
Gas Water Heater(s):
11 UNITHEATER(S): Wall Mount: Y N
Floor:
Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
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: 1-100,000 BTU:
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas ❑ ; 011 0 ; Coal 0 ; Wood Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; Heat Pump❑
1* Number of separate zones for any heating, A/C or air handling system.
2e°
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. j
SIGNATURE OF oi,,.J z/� APPLICATION f D
OWNER OR �- W�-1DATE t