1984, 07-20 Permit App: 00001299 Wood Stove A `� 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
6/57/L.A.--y egie Re A L Project No. /2-q -
2
2 Project Address(Not Mailing Address) Space Zip
66y'`/ /C IA S7. 994:11c
3 City/Community State Subdivision/Plat Name
5(70 C/,le_ A/
4 Assessor Parcel N . Lot Block
16 Contractor Firm Name Street Address
5A)44--y , GR2C5/1A L c'yc,Y / ih 5/
17 Zip City State Phone
‘260i/a 5Po1 A i AAA ( Sc3?) I--, e-,/r- y-5 c)- -----
18
----'18 Contact Person License No. Phone if different than above
1 ..i= l Al t, ........................ 02 a-S'4'01 P-lkr 3779(
8 Owner/Agent(if different than#1 above) Business Address
S i4 1'%s 661d i1Q-
9 Zip City State Phone
( )
15 Describe Work:
New ❑ Addition/Alteration ❑ Replace/Repair lEhr
10 Applicant Name Street Address
& . arv). L . 8 r t L .fr--- 04 7'&rh, ST
11 Zip City State Phone
qr -/c Ved Vci ( - viii ( ) r3e"
* *
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): I Solid Fuel: Gas Water Heater(s):
I- 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
W
2
a 12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM:
5
a
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
LL
0 -
W 14 1000-1750M: Other: Pressure Vessel(cu.ft.):
CL
I-
0 15 COMPRESSOR/HP: Lessthan3: 3-15: 15-30: 30-50: 50+:
Z
Q -
W 16 GAS PIPING SYSTEM:Number of outlets:
m
2
J 17 HEATING SYSTEM:1-100,000 BTU: 100,001+ BTU:
Z
18 TYPE FUEL SOURCE: Electric ❑ ; Gas ❑ ; Oil ❑ ; Coal D ; Wood CAS; Solar ❑
19 TYPE DISTRIBUTION: Forced Air ❑ ; Radiant ❑ ; Heat Pump 17
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 /� APPLICATION
OWNER OR /S 0--Oi• �� DATE 7/c /Fj"