1984, 09-30 Permit App: 00002584 Chimney, Woodstovet
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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)
I/
5 ®
Department Use Only
Project No.
2 Project Address (Not Mailing Address) t . foo . W(' (/ Space Zip
toT.S /3/4)‹,1.c. ,Z /2e. P/4.7'o- '/.�, Tl2 er s 4.L. d,D. 9524.
3 City/Community
5 !-c et 11
State
G41a. S L. „
Subdivision/Plat Name
/3• - 77i9 e e-
4 Assessor el�No. 0
Lot S I 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 91 above)
Business Address
g Zip
City
State
Phone
( )
15 Describe Work:
New ❑ Addition/Alteration 0 Replace/Repair 0
10 Applicant NameStreet Address
4 «/ w L,\, i IC 133/ ' "70 Z I• 4cle.�I
11 Zip
,7 2—/C
City
s AK 1
State
Gcia- s 1
Phone
(s -of) 2z_ ic/Y/ /
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/
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. t.):
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:
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18 TYPE FUEL SOURCE: Electric 0 ; Gas 0 ; 011 0 ; Coal 0 ; Wood Lal; Solar ❑
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant lile Heat Pump
.11
1* Number of separate zones for any heating, A/C or air handling system. 00.00
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,�_lc/
APPLICATION
DATE Y 3 0 —�7