1986, 10-31 Permit App: 00013933 Wood Stove MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project#
Owner's Na a Last First MI
ProLt Address(Street Name&Number)
) 9 � S pi r-oc1ctct
City Sta Subdivision/Plat Name
\- pe C1CSC VP ikkL '`f`
Assessors Parcel# Lot Block Plat#
I7 (&I
Applicant
Applicant Address
City State Zip Phone
3X/ 35
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 3-15H P 15-30H P 30-50H P 50+HP
1-5 Outlets 6+Outlets
Gas Piping
Gas Fired Heating System 1-100,000BTU 10,,,L00+BTU
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 - APPLICATION
OWNER OR .DATE