1985, 09-12 Permit App: 00007480 Wood Stove ,
- MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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i� Project# 71-/F/F
COwner's Name — r Last . first MI
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Project Address(Street Name&Number)
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City State Subdivision lPlat Name
Assessors Parcel#
�+ Lot Block Plat#
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Applicant Address -j,
City State Zip Phone
Business Phone
Contractor Address
City State Zip Phone
Contact License# Business Phone
Describe Work
Fans Evaporative Cooler Hoods Electric Furnace/Ducts Miscellaneous
Dryer Range Gas Log Gas Water Htr. Solid Fuel/Wood Stove
1
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
0-3HP 3-15HP 15-30H P 30-50H P 50+HP
Compressor
1-5 Outlets 6+Outlets
Gas Piping
Gas Fired Heating System 1-100,000BTU 10,,,X0+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 7 /1,2„._ 4S--
OWNER OR t,,,/i
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DATE