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1985, 09-19 Permit App: 00007576 Wood Stove • • MECHANICAL PERMIT APPLICATION WORK$NRtT PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND • Project# Owner's Name Last First Ml Project Address(Street Name&Number) City State Subdivision/Plat Name Assessors Parcel# Lot Block Plat# Applicant Address City State Zip Phone 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 0-3HP 3-15HP 15-30H P 30-50H P 50+HP Compressor 1-5 Outlets 6+Outlets Gas Piping 1-100,000BTU 10.,300+BTU Gas Fired Heating 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 al— 5