1985, 08-19 Permit App: 00007191 Insert1—
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
•
1 Owner's Name (Last) (First) (M) 1 Department Use Only .7/q/
Qu ak ke l as r John Project No.
2 Project Address (Not Mailing Address) Space Zip
S. 1121 St. Charles 99037
3 City/Community
Veradale
State
WA
Subdivision/Plat Name
e 'LA. S14. d'
4 Assessor Parcel No.LotBlock
-2;77144- 25O`7
-,-7
1 Blom
'I (i6 Ibc sfe._
16 Contractor Firm Name
Valley Fireplace
Street Address
E. 16610 Sprague --P0 Box 553
17 Zip
99037
City.
Veradale
State
WA
Phone
(509 ) 922-2780
18 Contact Person
License No.
VALLE F 177CG
Phone If different than above
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe work:Installation of Convector woodstove classic insert
New ❑ Addition/Alteration 0 Replace/Repair 0
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
8 VENT: Fan(s):
EvapCooler(s):
Hood(s):
Duct(s)1:
Miscellaneous:
10 APPLIANCE:
Dryer(s): 1 Range s):
Gas Log(s):
Wood Stove/
Solid Fuel:
Gas Water Heater(s):
11 UNIT HEATER(S): Wall Mount: Y N
Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. ft.):
15 COMPRESSOR/ HP: Lessthan3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU:
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric 0 ; Gas 0 ; 011 0 ; Coal 0 ;, Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; 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.
SIGNATURE OF COWNER OR
APPLICATIONS
DATE