1984, 11-07 Permit App: 00003243 Woodstove1—
Z
W
2
a
5
a
W
>
O
W
1-
0
Z
cc
tu
co
2
z
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name , (Last) First) (M) I Department Use Only
i
av ` C �0 1�'\ �1 . 'a�Q__ Project No.
V�
2 Pro ect Address (Not Mailing Address) t Space Zip j(
!LA `� �.N` W 19 . 99 Al
3 City//mun \
State
W c1 .
Subdivision/Plat Name —""
(101JT►tb0 0Yed CiTliK
4 Asses or Parcel No.
61141- /118
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 #1 above)
Business Address
g Zip
City
State
Phone
( )
15 Describe Work:
New ❑ Addition/Alteration
0 Replace/Repair 0
10 Applicant Name
Street Address
11 Zip
City
State
Phone
(so9) gam q9 i 0 4
8 VENT: Fan(s):
Evap Cooler(s):
Hood s):
Duct(s)1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
I
l Range s):
Gas Log(s):
Wood Stove/
Solid Fuel:
Gas Water Heater(s):
11 UNITHEATER(S): WallMount: 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:
1
Pressure Vessel (cu. t.):
15 COMPRESSOR/ HP: Lessthan3:
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 0 ; Gas 0 ; 011 0 ; Coal 0 ; Wood 0 ; 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.
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
APPLICATION
OWNER OR DATE