1987, 08-11 Permit App: 87002816 Wood Stove MECHANIGAL PERMIT APPLICATION WORKSHEET
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PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
007 llo0 1306 As
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Project# to7_02.8 itc,
Owner's Name Last First MI ( l tlJ
reFc AX is-1
Project Address(Street Name&Number)
15-8 e - I Y�
Ci y State Subdivision/Plat Name
v K i-- L,j 14 ''ere 4 ootZt) A-CMS
Assessors Parcel# 42#6, �� Lot Block Plat#
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Applicant Address
City State Zip Phone
Business Phone
Contractor Address
Thf - c ckv- -( S j 1c-r 5_ t _ d R/ ky
City 4 K \� ic-s uJi State , Zip ct?,_Q�_ Phone S-3 S! ?7C U
Contact License# Business Phone
Kt- PKW ( g anter ll t.t
Describe Work -
i1.-b , `CFF ,$itcic,k..Cr WikLI-, '01/4-)S 1)41...(- e_L.aks5 `A' ct,ki-v.N€)yj t-t' DIc Op SSV..
Fans Evaporative Cooler Hoods Electric Furnace/Ducts Miscellaneous
Dryer Range Gas Log Gas Water Htr. Solid Fuel/Wood Stove
A L 6-)r N ✓iA-t-( t (
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 15-30HP 30-50HP 50+HP
Compressor
1-5 Outlets 6+Outlets
Gas Piping
1-100,000BTU 10,,,,;00+BTU
Gas Fired Heating System
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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 OFV\ APPLICATION 1 i
OWNER OR .DATE �-1