1985, 01-10 Permit App: 00003890 Woodstovea
6c)°° MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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1 OZtdreasM2t2)1 's Name (L(First) (M)
' , 5Project
95rc
Department Use Only
No.
Space Zip
/17(19-- e./Q,ch
3 City/Community
State
141,—
Subdivision/Plat Name
/re L o 0 C/ Ore % 856,
4 Assessor Parcel No
0354/ — 2.
Lot 1 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 #1 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work:
New 0 Addition/Alteration 0 Replace/Repair 0
kppli9ant eStreet
W7"tm/I
Address
5 2-7.24 A2 -014m1
11 ZipCity
9la 1
•�ii L,�,
t"I rQ )� 1Stateceii_
le_
Phone
1 )90V / P97-5 97-5
8 VENT: Fan(s):
Evap Cooler(s):
Hood(s):
Duct(s)1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
I Range. s):
Gas Log(s):
Wood Stove/ of
Solid Fuel:
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 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. ft.):
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 jj 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
OWNER OR
APPLICATION _�
DATE f—/()