1986, 10-10 Permit App: 00013710 WoodstoveMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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�I
OWNER OR "`mac L��f
APPLICATION
DATE
A.; (3
Project # ,/O
Owner's Name Last First MI
R:;/ / / /c° - :«
Project Address (Street Name & Number)
-s . 8'-=^7 Woc,cQ,, JcP R.O.
City
State
c}
Q.)
Subdivision/Plat Name
A6sessors Parcel#
2 4
Lot
1
Block
Plat$
Appt' nt
a MC f; ., t0 /
C
Address
/Y. ///q /tQ„ 4/
City
/4o /c 4 v1 e
State
C. .
Zip
cl 9 .Z(- 1—
Phone
''i �v1 1 - 9 39
Business Phone
3; 2- 3a 1
Contractor
.,(C) /11''4.�� d /).0 ,
Address
/V ///1 /i).,4/
City
.5 ,/\4Ae
State
L3
Zip
9 .2c r1-
Phone
s-? o l
Co tact
Pj't k SC 1,1 J C c 4 r
License#
ce�/
/ gU //C/q3AI 3
Business Phone
1 :1) - i- 3,
�Describe Work f �/
ns.,,,, (7 S/),c i A 5/v•-Jc (0(,jl'
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/Wood Stove
iJ--.
Y
Air Handling Units
0-10,000CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-3OHP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6 + Outlets
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�I
OWNER OR "`mac L��f
APPLICATION
DATE
A.; (3