1984, 08-14 Permit App: 00001811 Wood Stove MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) / (First) (M) Department Use Only k",51//
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_ �( �? 4' .// ,) r', h N Project No.
2 Project Address(Not Mailing Address) Space Zip
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3 City/Community State Subdivision/Plat Name
C ceE4/4 e4 /1i N. V91,L A-y t, /) �1 -t:-
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4 Assessor Parcel No. Lot Block
IE�5/ '. 272 L 1.�
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 ❑ Addition/AlterationReplace/Repair 0
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: I (Wood Stover
Dryer(s): Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
I— 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
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a12 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:
LL
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W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
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0 15 COMPRESSOR/HP: Less than 3: 3-15: 15-30: 30-50: 50+:
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W 16 GAS PIPING SYSTEM:Number of outlets:
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2
D 17 HEATING SYSTEM:1-100,000 BTU: 100,001+ BTU:
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18 TYPE FUEL SOURCE: Electric ❑ ; Gas ❑ ; Oil ❑ ; Coal ❑ ; Wood X; Solar 0
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.
OWNERU
UORSIGNATREO -'c"� -1.-A_ (-6 / X e, -C/L4,-A--C DATE APPLICATION ����(� Z
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