1985, 01-21 Permit App: 00003995 Fireplace -
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) r-!st)� (M) Department Use Only
_ S j o s t rom V Lc(44 T_ Project No.
2 Project Address(Not Mailing Address) Space Zip
E 16415 Riverside Q9 '37
3 CIty/Community 1 State Subdivision/Plat N;�
Spokane, Wash Verb /gip/G-'
4 Assessor Parcel No. Lot
iar5I �- /365 t / I Block
L 3Q-c4I(aa
16 Contractor Firm Name .Street Address
Pleasant Prairie Farms Custom Mfg. Inc. E 7827 Bigelow Gulch
17 Zip City State Phone
99207-9698 Spokane Wash ( 509) 467 6760
18 Contact Person License No. Phone If different than above
4.B. Gramlow 223 01 Pleasi*229JE
8 Owner/Agent(If different than#1 above) Business Address
9 Zip City State Phone
( )
15 DescrlbeWork:In9tal1 Custom FP. Insert. Customer responsible for Hearth
New ❑ Addition/Alteration 0 Replace/Repair ❑ ext. if needed
10 Applicant Name Street Address
11 Zip City State Phone
( )
* *
8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: Miscellaneous:
10 APPLIANCE: Wood Stove/
Dryer(s): I Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
Z 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N
Suspended: Y N
W
a 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
5
0
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
U-
0
a 14 1000-1750M: Other: Pressure Vessel(Cu.ft.):
I—
a 15 COMPRESSOR/HP: Less than 3: 3-15: 15-30: 30-50: 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets:
CO
2
D 17 HEATING SYSTEM:1-100,000 BTU: 100,001+BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas ❑ ; Oil 0 ; Coal 0 ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air ❑ ; 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 0-# / `- 2 ley / APPLICATION
/
OWNER OR . / '` J DATE 7---,0.27-436---