1985, 09-04 Permit App: 00007249 WoodstoveMECHANICAL 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.
SIGNATREOWNERUOROFr��/� ���77/1 DATE CATION �y— '14eFr,.
Project # -72 `T9
Owner's Name f�%L'asstt First MI
% ^
Project Address (Street Name & Number)
/47r-- 5, Ale -c-6, --
City
p�X,4-y,E
State
A- 997-1
Subdivv n/Plat Name
UPPO RTt ury rr/ l ER,�AC�E
Assessors Parcel #2-15 / / — /743
C/L
Lot S
Block 3
Plat #
Applicant
Address
City
I
State
Zip
Phone
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
License #
Business Phone
Describe Work
Fans
Evaporative Cooler
Hoods
ElectricFurnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/Wood Stove
Air Handling Units
0-10,000CFM
10,000+ CFM
Refrigeration Systema/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15 -301 -IP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10u,4300+ 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.
SIGNATREOWNERUOROFr��/� ���77/1 DATE CATION �y— '14eFr,.