1986, 08-28 Permit App: 00012869 Wood StoveMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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
OWNER OR /� v
APPLICATION a
4:2,77-,--
DATE v -I
Project# /.2p6`7
Owner's Name last First MI/
4-20 L i 11 Ill reY p1/4 Anil it p1 a 4 11-(e (e y
Project Address (StreiName & Number)
1 -.?41/ o 6 Ai x 1.�.Pr //
•City State
%-/-eeFiti«c,-e,s IL<Gz S' 4`
Subdivision/Plat Name
Assessors Parcel #
Lot
Block
Plat #
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
License #
Business Phone
Describe Work
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Wr.
Solid Fuel/Wood Stove
Air Handling Unite
0-10,000CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over1750M
Compressor
0-3HP
3-15HP
15-3OHP
30-5OHP
50-F HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
1U,,L00+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 OF
OWNER OR /� v
APPLICATION a
4:2,77-,--
DATE v -I