1984, 10-12 Permit App: 00002868 Insertw
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M)
Hensley Robert G
Department Use Only
Project No.
2 Project Address (Not Mailing Address) Space Zip
E. 13312 Rockwell Avenue 99216
3 City/Community
Spokane
State
WA
Subdivision/Plat Name
&i f NcV &1b
4 Assessor Parcel No.
035 / —13cst
Lot
Block
-.
hF
__2
16 Contractor Firm Name
Valley Fireplace
Street Address
E. 16610 Sprague
17 Zip
49037
City
Veradale
State
WA
Phone
(509) 922-2780
18 Contact Person
License No.
VALLEF 177CG
Phone if different than above
8 Owner/Agent (if different than 81 above)
Business Address
9 Zip
City
State Phone
)1( )
15 Describe Work: Install Lop 520 stove, pipe and heart
New ❑ Addition/Alteration 0 Replace/Repair 0
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
8 VENT: Fan(s):
Evap Cooier(s):
Hood(s):
Duct(s) 1:
Miscellaneous:
10 APPLIANCE:
Dryer(s):
I Range(s):
Gas Log(s):
Wood Stove/
Solid Fuel:
Gas Water Heater(a):
11 UNIT HEATER(S): Wail 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 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant 0 ; 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.
SIGNATUREOF C �-j------ Q APPLICATION if,
OWNER OR0- Il -SAP U(^� 1 � DATE