1984, 11-28 Permit App: 00003641 Wood StoveH
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name ast) t) (M) Department Use Only ,
.mac-/��----2-r/ Project No.
2 Project Address (Not riling Address) Space Zip
/.- - 1 cj 77)-76
3 City/ vr unity /
.AO
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Stat
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Subdivision/ Plat Name
Kra(' eN f Gv,Cc% ('r', i`c/S
4 Assam 'or Parcel No.
( 11 / — rr 6
Lot
Block
16 tractor Fir NameU
-ss Street A.)- .- ..
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17 Zip
7-7..1„,e,-
City //
State
Phone e
(-5';-, 'L,P:_ —lo/7
Phone if different than above
18 # t Person
License No.
:ArOwnef gent (if different than above)
Business Address
g Zip
City
State
Phone
( )
15 Describe Work: �2 -?.-- �� .--7, -c°
New 13'- Addit /Alteration
f--zti-e- .C- .<-0C7c- -`
❑ Replace/Repair ❑ �
10 Applicant Na
Street Address
11 Zip
City
State
Phone
(
8 VENT: Fan(s):
Evap Cooler(s):
Hood s):
Duct(s) 1:
Miscellaneous:
10 APPLIANCE: 1
Dryer(s):
Range s):
Wood St
Gas Water Heater(s):
Gas Log(s):
Solid Fuel:
11 UNIT HEATER(S): WaIIMount: Y N
Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. t.):
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 ❑ ; Coal 0 ; Wood Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant Heat Pump CI
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
OWNER OR
APPLICATION/
DATE
*