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1986, 10-31 Permit App: 00013953 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 APPLICATION OWNER OR DATE Project // t Owner's Name Last First MI Project Address (Street Name & Number e. ?di /dorms City�/�o�j ^ie_d State 2J/42Subdivision/Plat Name Assess rs Parcel# Lot Block Plat Applicant ,,/ &J /-'�J/ CLC/( c-- V..2)47)0117&_) Address Ji/I')2P-----"' City _.---ya—agi)/ State Zip Phone Business Phone Conlraclo/L-7 5 n %/ C Address City State Zip Phone Contact it/License # Business Phone yityJe/ r Describe Work INo00 SWOT Fans Evaporative Cooler Hoods Electric Furnace/Ducts Miscellaneous Dryer Range Gas Log Gas Wate Htr. Solid Fuel/Wood Stove Air Handling Units 0-10,000CFM 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 l-100,000BTU 1 W,100+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 APPLICATION OWNER OR DATE