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1986, 09-03 Permit App: 00012946 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. SIGNATUREOF 1 tem �� APPLICATION q_���4 OWNER OOR /L DATE Project # Owner's Name Last First MI gD.1/416- 6,92y -,— Project Address (Street Name & Number) 394.2./ /Jiss/o,J Cttty' �o ie/94)o State �� �/] ai. 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 Htr. Solid Fuel/ Wood Stove Air Handling Units 0-10,000CFM 10,000+ CFM Refrigeration Systems/ Haat 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 - 1-100,000BTU 10v,(.)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. SIGNATUREOF 1 tem �� APPLICATION q_���4 OWNER OOR /L DATE