1986, 05-06 Permit App: 00011402 Fireplace r
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project# i / 4 C)Owner's Name Last First MI l
Cor,ley Fabert )',
Project Address(Street Name&Number)
E. /e00i0 RreM
CityC., State Subdivision/Plat Name
Spo, an e Wa-, .,Eu.-Et,—-( ,nn IA AOz •Z,v n
Assessors Parcel# Lot Block Plat#
a>l,42-2-7c z 044;Li2
Applicant 77 ereset_ /,4 , Address
o,lley E. 160/D Rich
City , State Zip Phone
pok .r►.es Wa , 9ga 1c 9 --38?Ca
Business Phone
90.a- WOO) e)61 . 361g
Contractor Address
13r ll hied 1/i,yer S4- R. MQsonry
City State Zip Phone
C. kane, WO , 535– z/05 5
Contact License# Business Phone
Sante
Describe Work ,
¢trepla&?i (Maseel(Li) rn talked 1n basement w/ e isfi..y 11/u e. ,
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
Compressor 0-3HP 3-15HP 15-3OHP 30-50HP 50+HP
1-5 Outlets 6+Outlets
Gas Piping
Gas Fired Heating System 1-100,000BTU 1(1,0;00+BTU
-0 as,cx)
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 (% '1 DATE J; 14