1985, 11-18 Permit App: 00008764 Wood Stove . p -
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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45
Project# 7/"
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Owner's Name Last First MI ([
Project Adcpss(Street Name&Number)
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StateSubdivision/Plat Name
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t9dsessors Parcel# Lot Block 1Plat#
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App Address
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CiState Zip Phone /
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Business Phone
Contractor Address
City State Zip Phone
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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
I
0-10,000CFM 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
1-100,000BTU 10.0;00+BTU
Gas Fired Heating 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 ` 44-4C-12_ APPLICATION /�OWNER OR -, ,.�.wo DATE �f �