1986, 10-09 Permit App: 00013542 Wood Stove /b-/tt-
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MECHANICAL PERMIT APPLICATION WORKSHEET ACT-"2 P Al
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project# r 3 Jr, , z
• •er'sName at Last First Mi ��
a, tN k 'cle_i
Pro ect Address(Street Nameumber)
5019 Pe 5
City State SubdPjos *
on/Plat Name
1pA.
6-k a .9- Ui)cx 1n Sum
Asses ors Parcel# Lot Block Plat#
35(0 it 3 - oC>/ 1 1
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
I
Air Handling Units 0-10,000 CFM 10,000+CFM
Refrigeration Systems/ 1-100M 101-500M 501-1,000M
Heat Pumps(BTU)
1,001-1750M Over1750M
Compressor 0-3HP 3-15HP 15-30HP 30-50HP 50+HP
1-5 Outlets 6+Outlets
Gas Piping
Gas Fired Heating System 1-100,000BTU 10,,,,.:00+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 —
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OWNER OR ✓l /�� 7 ()A �`1' DATE � —