1986, 08-18 Permit App: 00012695 Wood Stove •
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project# /14,46 14,/'�6
Owner's Name Last First M
Project Address(Street Name&Number)
E: /2471e'F s;:e- t1/e A
City,....., State Subdivision/Plat Name
3 Po fe4A)6- c.34 Ni 4-NJ( Et-c) kpr 2- &k 7
Assessors Parcel# _ 3 - 0� Lot Block i Plat#
2J
Applicant 1 S(/{ Address
5-A M..
City State Zip Phone
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 Fue I Wood Stove
0-10,000CFM 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 15-30HP 30-5OHP 50+HP
1-5 Outlets 6+Outlets
Gas Piping
1-100,000BTU 10,,:00+BTU
Gas Fired Heating 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 provis' of any state of local laws regulating construction or the performance of
construction.
SIGNATURE OF �� / APPLICATION
OWNER OR �' /-I- ,r- -.1r> .DATE Of