1986, 09-10 Permit App: 00013231 Wood Stove MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
_115-1/1/ _ / 1 Project# M2
Owner's Name Last First MI
J in i 11) kV'/a h
Project Address(Street Name&Number) h
/0508 L-_ . /0
City State Subdivision/Plat Name
5 ,vi Rn f_ IL) iq 9' 0
Assessorsiparcel# Lot Block Plat#
Wilk ite/8QQ
Applicant Address
U ✓l LL a y -/ it e pJAo � . /(O 6/0 e• d
City State Zip Phone
Ue rPCOP-te- (/) A 1 02 7 9.) D - D -78 u
Business Phone
Contractor Address
1/1 P II e ca ,rice 1. g -e-' f-. /6,6/6 ,5p!` j cr,�
City / State Zip Phone Q
(j err cf4ice_ i.JA 99d.;) 7 2 . . - D. "78O
Contact License# Business Phone
() A--4-Lc- y 77C6—
Describe Work / _y,. I n ;j 7. -�-
--.1--- J�fv?.✓'./l.. `��'7'�Cs . ! c. (�nbS1 ✓ .. \Tr. y ---+--. 'A �(/.�t.1r'...\,t st .�ll/M. /1_�
i A b2 U/�h o L,`
Fat 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 30-50HP 50+HP
1-5 Outlets 6+Outlets
Gas Piping
Gas Fired Heating System 1-100,000BTU 10o,;: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.
SIGNATURE OF ri --j-- APPLICATION
OWNER OR \,...c,- i \,^_9i ., ,_ t ) . , v(1,?�--� DATE °-\ III s t ->4