1986, 07-29 Permit App: 00012371 Wood Stove MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
"Sr)
Project# 127
Owner's Name Last First MI
4/W Z 7fv�=�ti
Project Address(Street Name&Number)
/r 2-22 /'/74A
City State Sub ' 'Sion/Plat Name
G/E61), E lvs} TCI(FORD ACRE—TRS
Assessors Parcel# 0306 Lot Bloch Plat#
to
Applicant Address
City State Zip Phone
Business Phone
Contractor Address
City State [License
Zip Phone
Contact # Business Phone
Describe Work
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 30-5OHP 50+HP
1-5 Outlets 6+Outlets
Gas Piping
Gas Fired Heating System 1-100,000BTU 10,,,J..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.
SIGNATOWNERURE OROF� APPLICATION
/S- .DATE 7- 2?-,f-