1984, 09-21 Permit App: 00002441 Wood Stove MECHANICAL PERMIT APPLICATION WORKSHEET
•
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) . (M) Department Use Only
\. J S L__.-- - ---v- te e.:.) A, Project No.
2 Project Address(Not Mailing Address) pace Zip
. k.,(',,,--Cl.cLk LAD CAAD Ct_ S AVS c{ ct. 1 (,.
3 City/Community State SujJe(?es
vision/ Name
- v KOLi e w (eci Afaiver y4h 4d
4 Asse§sor Parcel No. Lot Block
\ && 5 diget2,. 2t,4//
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 Applicant Name Street Address
11 Zip City State Phone
( )
• *
8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: Miscellaneous:
10 APPLIANCE: Wood Stove/
Dryer(s): I Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
1— 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
Z
W
2
d 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
5
0
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
U-
O
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
a
›-
l-
0
0 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets:
m
2
3 17 HEATING SYSTEM:1-100,000 BTU: 100,001+ BTU:
Z
18 TYPE FUEL SOURCE: Electric ❑ ; Gas ❑ ; Oil ❑ ; Coal ❑ ; Wood 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.
r9.SIGNATURE OF/j, APPLICATION 9,/
, '
OWNER OR q p DATE