1986, 04-30 Permit App: 00010785 Woodstove--- MECHANICAL 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 # t0.1 SSS
Owner's Name Last First MI
rC\k-C F Sr- L .
Project Address (Street Name & Number)
------ \V1\2 _ C\mow kc
City J
�o\C GhS
State
� Q—
Subdivision/Plat Name
S4 fm VVV v4
—t ELD gAst 1 --(—
Assessors Parcel #Lot
Assessors
3 S('9C4 — ZCeb°57
Block
Plat #
Applicantf,
0-..c:�r:.
Address
C..._. \y�l \2,. S\y,. ,c)t
City
c,e��LRS c�
State
_C3.� _
Zipipp
—\ \Z\\p
Phone
sr-L—C1 — \okz:-
Business Phone
`�— S`1C)f, C\IV1s1Oc k)
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
r
0-10,000 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
'1,001-1750M
101-500M
501-1,000M
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
10u,�00+BTUP
2. $ . 6> C2
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