1985, 03-15 Permit App: 00004559 Woodstove*
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MECHANICAL PERMIT APPLICATION WORKSHEET 4
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
be les
1 Owner's Name (Last) (First) (M)
VALE
Department Use Only
Project No.
2 Project Address MailingAddress) Space Zip /O'
3 City/Community
State
Sinn/Plat Name ��� (:),buA-- c -ego t PS
4 Assessor Parcel No. _
07.55/.57 77/�
Lot
I Block
c-
%- f
16 Contractor Firm Name Street Address
c/- X i /IELb Ciiiltl / 5L lit( _e W67 ?duc
17 Zip
q'420-7
City
0,(406�-r_
State
tA.--
Phone
(50) z.04-6164
18 Contact Person
14/ 1,071 Kpkgt ofaa�s
License No.
122P-1-4
Phone if different than above
8 Owner/Agent (if different thstn #1 above)
Business
Address
9 Zip
City
State
Phone
( )
15 Describe Work: T�5TML�D HE T�rj16NE1I
New P�J-�r-o Ot.J Addition/Alteration
❑
Replace/Repair ❑
10 Applicant Name
Street
Address
11 Zip
City
State
Phone
( )
8 VENT: Fan(s):
Evap Cooler(s):
Hood(s):
Duct(s)1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
I Range s):
Gas Log(s):
Wood Stove/, let ii's
Solid Fuel: l 44-
Gas Water Heater(s):
11 UNIT HEATER(S): Wail Mount: 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:
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 ❑ ; Gas 0 ; Oil 0 ; Coal 0 ; Wood f 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
OWNER OR
APPLICATION
DATE , /5 95