1986, 02-21 Permit App: 00009781 Wood Insert MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project#
Owner's Name
Last First MI
I
Korn -,1
Project Address(Street Name&Number)
S. 2717 Collins
City 'State SubdivisionQ I Plat Name
Spokane 1:iA 99216 -I AltU Block i n 6 Plat#
Assessors Parcel# _a// Lot
� I
Applicant I Address
Valley Fireplace E. 16610 Sprague — PO Box 553
City I State I Zip Phone
Veradale VA 99037 922-2780
Business Phone
Contractor Address
Valley Fireplace r;. 16610 Sprague — PO Box 553
City State Zip Phone
Veradale VA 99037 922-2780
Contact License# Business Phone
VALLEF-177CG
Describe Work ''td I/�tl)��
Installation of Convector 0 Insert.(/ (J -t
Fans Evaporative Cooler Hoods Electric Fi(nace/Ducts Miscellaneous
Ran a Gas Log Gas Water Htr. Solid Fuel/Wood Stove
Dryer g
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 15-30H P 30-50H P 50+HP
Compressor
1-5 Outlets 6+Outlets
Gas Piping
1-100,000BTU 10v,:00+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 OFC i I -- APPLICATION � �"'�
i4j-4
OWN
ER OR t\:-,—g-iti4 9--, .DATE