1985, 09-17 Permit App: 00007503 Wood Stove MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
JNM 5rtitPsoi./
Project#
Owner's Name Last First pMII
Project Address(Street Name&Number)
/rgi8` /5 •
City State Subdivision/Plat Name
/5<c:0.9 . (. 1,,\r6R-tST / e-t713 t s-r
Assessors Parcel# �tf� L�J � /1/5 lot � Block 9., Plat#
Applicant Address
City State Zip Phone
Business Phone
Contractor Address
City State Zip Phone
Contact License# Business Phone
Describe Work
Fans Evaporative Cooler Hoods Electric Furnace/Ducts Miscellaneous
Dryer Range Gas Log Gas Water Htr. Solid Fuel/Wood Stove
0-10,000CFM 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 15-30HP 30-5OHP 50+HP
Compressor
1-5 Outlets 6+Outlets
Gas Piping
1-100,000BTU +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 APPLICATION
U9 "/7-8�
OWNER ORS .DATE