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1986, 12-26 Permit App: 00014612 Wood Stove
I Ill MECHANICAL PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND G5 Ie Project# /1/6/S' 1/6/n Owner's Name Last First C-� MI L� Project Address(Street Name&Number) s 5M ( S v en Cr City State Sub ' ' n/Plat Name i'.. 1A14 , C9 2c4, pivDE © IttaiS Asse sors Parcel# c i` /`!/ - � Lot ii____ Block/ Plat# ) Q Applicant 5 !( 14 jT _ Address IL�14 f� City State Zip Phone ' Business Phone Contractor Address ---Psi P rqtki-/ C(-ti 1 kl'\.1,Ije-- ( ,,;t-'6 k ET- e,-; . (3e)g fot---(City State Zip Phone _ *7 • --7kX•ik-6L.l. vil cc, Z._ Contac License# Business Phone Describe Work __ _ 1 ik �C-CY L ti et ,�C t( �7. t-- - GLC t Lt-1t< 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 3-15HP 15-3OHP 30-5OHP 50+HP 1-5 Outlets 6+Outlets Gas Piping Gas Fired Heating System 1-100,000BTU 10,,,00+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 r APPLICATION }2 ,26 , (_ OWNER OR vz,4"(_ _.DATE (� �' '"