1986, 12-11 Permit App: 00014492 WoodstoveMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTSOF THE FORM YOU UNDERSTAND
3600
MSS
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
Project If /4� ' n
Ji--/
Owner's N� Last First MI
i �� I���S �-
..t
Project Address (Street Name & Number)
1 'C)301ocr L
r
Subdivision/Plat Name
Assessors Parcel N !7 ` t 'm 2. _ / ♦
5 /T/ /v, /'TL
Lot i
Block %
*`f�,••
Plat #
Appl l t
Address
ty
Dkas(�
State
11.DC
Zip
94.ok,
Phone
Q'.L(-o3<3
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
License 0
Business Phone
Describe Work
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel /Wood Stove
%
Air Handling Units
0-10,000CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
'1-5
15-30HP
30-50HP
50+HP
Gas Piping
Outlets
5+ Outlets
Gas Fired Heating System
1-100,000BTU
1Q,,; OO+BTU
4 25.0a
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