1985, 01-14 Permit App: 00009389 Wood Stove .-_ _ _-
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MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project*
Owner's Name Last First MI
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Project Address(Street Name&Number)
City State Subdivision/Plat Nam
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Assessors Parcel# Lot Block Plat#
ApplicantAddress
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City State Zip Phone
> kAra t v P -( 12./ c. 2. 7 -874 C
Business Phone
Contractor ,., Address
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City State Zip Phone
Contact License# Business Phone
Describe Work )
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Fans Evaporative Cooler Hoods Electric Furnace/Ducts Miscellaneous
Dryer Range Gas Log Gas Water Htr. Solid Fuel/Wood Stove
0-10,000 CFM 10,000+CFM
Air Handling Units
Refrigeration Systems/ 1-100M 101-500M 501-1,000M
Heat Pumps(BTU)
1,001-1750M Over 1750M
Compressor 0-3HP 3-15HP 15-30HP 30-50HP 50+HP
1-5 Outlets 6+Outlets
Gas Piping
Gas Fired Heating System 1-100,000BTU 10v,;A0+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 '---_._ APPLICATION 1_14– es—
OWNER
14- 8SOWNER OR --- Y�� .DATE