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