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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-