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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