1984, 10-30 Permit App: 00003081 Wood Stove•
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
/ 1 er' Narpe , L(Cait) //� \ (First) (M)
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Department Use Only
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Project Na.
2 Project Address (Not Main g Address) Space Zip
Rdr p
(/1�'13LpOq (nim 9ci 26 (a
3 City/ munit
po1e-a ike 1,00 sl�l,
Sta e // S h,
Subdivision/ Plat Name
041-1,11)yI E w Acf2E4 15 0.
4 Assessor Parcel No
04 s14-- 0 3z5
Lot
Block
16 Contractor Firm Name
Street Address
17 Zip
City
State
Phone
( )
18 Contact Person
License No.
Phone if different than above
8 Owner/Agent (if different than 41 above)
Business
Address
9 Zip
City
State
Phone
( )
15 Describe Work
New ❑ Addition/Alteration ❑
Replace/Repair 0
10 Applicant Name
Street
Address
11 Zip
City
State
Phone
( ) L, 74 -45"70
8 VENT: Fan(s):
Evap Cooler(s): .
Hood(s):
Duct(s) 1:
Miscellaneous'
10 APPLIANCE:Wood
Dryer(s)'
Range s):
Gas Log(s):
Stove/
I Solid Fue : (1
Gas Water Heater(s):
11 UNIT HEATER(S): Wall Mount: Y N
Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M•
500-1000M:
14 1000-1750M:
Other:
c
Pressure Vessel (cu ft I'
15 COMPRESSOR/HP: Less than 3:
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 0 ; Gas 0 ; Oil 0 ; Coal 0 ; Wood ❑ ; Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant ❑ ; 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
APPLICATION
OWNER OR DATE