1984, 09-07 Permit App: 00002199 Wood Stove MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name,� 4(Last) (First) / (M) Department Use Only
C'/ (ii!� /C tC. / (--((-:o r i'
I� � Project Na.
2 Project Address(Not Mailing Address) -, Space Zip
3 City/Community State Subdivision/Plat Name
4 Assessor/Parcel No. Lot Block
16 Contractor Firm Name Street Address
17 Zip City State Phone
( )
18 Contact Person License No. Phone if different than above
r
8 Owner/Agent(if different than#1 above) Business Address
9 Zip City State Phone
( )
15 Describe Work:
New ❑ Addition/Alteration ). Replace/Repair El
10 Applic Narn Street Address ,/ ,
•
11 Zi City State Phone
yJ C�C:� t"-_17/1 -Ci` 6 (1 /_/'� be`l) %_2 ,FC) j
* *
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):
Z 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
W
a12 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:
LL
O -
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
a
>I-
0 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
Z
Q
W 16 GAS PIPING SYSTEM:Number of outlets:
co
2
0 17 HEATING SYSTEM:1-100,000 BTU: 100,001+ BTU:
Z
18 TYPE FUEL SOURCE: Electric ❑ ; Gas ❑ ; Oil ❑ ; Coal ❑ ; Wood t Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; Heat Pump El
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. j
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SIGNATURE OF ^ 2// / APPLICATION �'
OWNER OR / DATE