1987, 01-15 Permit App: 87000101 Wood Stove •
MECkANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
001'1(SP-7
Project# /0
Owner's Name Last First
LIF, AND
Project Address(Street Name&Number) 77
15l3 / 2 '- 77 go,
State Subdivision/Plat Name
t//161-
Assessors Parcel# Lot Block Plat#
7 354
2-c
Applicant
Applicant Address
City State Zip Phone
Business Phone
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
0-10,000 CFM 10,000+CFM
Air Handling Units
Refrigeration Systems! 1-100M 101-500M 501-1,000M
Heat Pumps(BTU)
1,001-1750M Over 1750M
0-3HP 3-15HP 15-3OHP 30-5OH P 50+HP
Compressor
1-5 Outlets 6+Outlets
Gas Piping
1-100,000BTU 1Q,,.00+BTU
Gas Fired Heating 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/ ; j/ // /) ' APPLICATION %-_ % 7
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