1985, 06-19 Permit App: 00005989 Wood Stove MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project#
Owner's Name Last First MI
/-r,
Project Address(Street Name&Number)
reP/ (�
7 /S S. I p.L../01.9-1 L.0
City State Subdivision/Plat Name
Assessors Parcel# Lot Block Plat#
()4442 - 0 1 ` = ,4 :-/
Applicant Address
v/2-2
City State Zip Phone
Di 0 Kai
Business Phone
Contractor Address
City / State Zip Phone
Contact / License# Business Phone
Describe Work
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 10v, 00+BTU
/<./u<. ..vs <, � 76 S.(' 1C. 1 71". ,, r,-
C�,ti C.r), . k c , /21k--41 ;r r:— n�
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 OFA _� APPLICATION
OWNER OR -a (��I j7:-w K=Gl7 rv�..1,-.DATE --9?"fes