1986, 02-21 Permit App: 00009761 Wood StoveMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1006
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
_ �l'ti`" `_ DATE CATION 2-27-76
Project p e/ 76/
Owner's Name Last First MI
-
l�i/lin/4AI 672%? L
Project Address (Street Name 8 Number)
6 -/3 -Vo fre stJ.¢xw€2--L 06 fere
City
G/ZLE._{moi /2G-�
State
L✓,/a-
Subdivision/ Plat Name
\%ALL.-/ VI Ew
Assessors Parcel11/
1855 ( -s2.51./
Lot
fn -
Block
/a
Plattf
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
Licensee
Business Phone
Describe Work
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Hh.
Solid Fuel/Wood Stove
Air Handling Units
0-10,000CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
'
Gas Fired Heating System
1-100,0o0BTU
10,,;,00+BTU
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
_ �l'ti`" `_ DATE CATION 2-27-76