1986, 09-23 Permit App: 00013637 Wood Stove MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project# 6&/. 7 37
Owner's Name Last Irst MI ([J
Project Address(Street ame&Number) J '
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4// //.G.��� �---[-Ae-
City State Subdivision/Plat Name
Ass rs Parcel# Lot Block Plat#
6400
c%9 -e -2- —-�-t- ."---r--e-e--g- .c---e i �i Address .)'>- >j),,, ' ., ----c-e _
City State Zip 9 Phone/ /"
Business Phone
Contractor • Address
--7-Tic-(2-- a.-/-_ GE - cr-+L--.yz-74 t
City State i�',," Zip Phone
1/�c s i< �--�J' - a i ere 0 II G-�^-� 4��—/o / 7
nse# Business Phone
c Sc� I Work
-".--- --1-4-/-/e.ete,---- ille---ate,t-C-. .3,04 ,.se-----c.-'--e- et / e--Z---,-„,c--7,__e,
Fans Evaporer Hoods Electric Furrcts / Miscellaneous
Dryer Range Gas Log Gas Water Htr. Solid Fuel/Wood Stove
Air Handling Units 0-10,000 CFM 10,000+CFM
Refrigeration Systems/ 1-100M 101-500M 501-1,000M
Heat Pumps(BTU)
1,001-1750M Over 1750M
Compressor
0-3HP 3-15HP 15-3OHP 30-50HP 50+HP
1-5 Outlets 6+Outlets
Gas Piping
Gas Fired Heating System 1-100,000BTU 10v,�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 - e/ APPLICATION
OWNER OR c � .DATE 9, :1G