1984, 11-16 Permit App: 00003395 Wood Stove MECHANICAL PERMIT APPLICATION WORKSHEET
' PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
` 1 Owner's Name (Last) _ Y�(Firt) (M) Department Use Only
W fM Y(3, /�1-�I Project No.
2 Project Address(Not Mailing Address) Space Zip
3 City/Community State Subdivision/Plat Name
•
VE,c4 p/,A _ (._6)A- �` :Mbet/cave,
•
4 Assessor Parcel No. Lot Block
16 Contractor Firm Name Street Address
17 Zip City State Phone
( )
18 Contact Person License No. Phone if different than above
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work:
New ❑ Addition/Alteration ❑ Replace/Repair ❑
10 Applic t Name �_. Street Address a
YL .T7". l >/23:417/6—.74L/ : 7r /i�C .e4,4/1/E- Dom.
11 Zi, City State Phone
8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: Miscellaneous:
10 APPLIANCE: Wood Stove/
Dryer(s): Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
H 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
d12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
2, 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
LL
� I 0
14 1000-1750M: Other: Pressure Vessel(cu.ft.):
CL
>I-
O 15 COMPRESSOR/HP: Less than 3: 3-15: 15-30: 30-50: 50+:
W 16 GAS PIPING SYSTEM:Number of outlets:
2
Z 17 HEATING SYSTEM:1-100,000 BTU: 100,001+ BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas ❑ ; Oil ❑ ; Coal ❑ ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant ❑ ; 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 APPLICATION
OWNER OR DATE