1984, 12-28 Permit App: 00003826 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
e rn�e
[ G , Project No.
2 Project Address(Not Mailing Aggress) Space Zip
- tS15/ // ileS1 79� l
3 City/Community State Subdivision/Plat Name
4 Assess r Parcel No. Lot Block
L
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
g Zip City State Phone
( )
15 Describe Work:
New D 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: I Wood Stove/
Dryer(s): I Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
Z 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
W
2
d 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
5
O
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
U-
O
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
a
>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 D ; Gas ❑ ; Oil ❑ ; Coal 0 ; Wood ❑ ; Solar ❑
19 TYPE DISTRIBUTION: Forced Air 0 ; 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 e APPLICATION c/
OWNER OR (gi�_r .tX l DATE