1986, 05-23 Permit App: 00011207 Wood Stove. MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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Project#
Owner's Name Last First MI
Project Address (Street Name 8 Number
5 832 O moh /-yodiar'/ 7 92/-2--
City
✓,4701,lvl7 L.—
State
1 211
Subdivision/ Plat Name
Assessors Parcel #
Lot
Block
Plat #
Applicant
Address
City
State
Zip
Phone ZL — L 1 0
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
License #
Business Phone
Describe Work //��,,��p 9)U/n
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Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr
Solid Fuel/ Wood Stove
Air Handling Unite
0-10,000 CFM
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
1-100,000BTU
1Q,,:.W +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 /J
OWNER OR £ Z' c6ki" Cly
APPLICATION S
DATE /23AP,c'