1984, 11-15 Permit App 00003415 Fireplace InsertMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M)
Easl ing Jim
Department Use Only
Project No.
2 Project Address (Not Mailing Address) Space Zip
E. 9705 Crossbow Court 99206
3 City/Community
Spokane
State
WA
Subdivision/Plat Name
eice.icr % PCreS t
4 Assessor Parcel No.
Lot
Block
r
16 Contractor Firm Name
Valley Fireplace
Street Address
E. 16610 Sprague
17 Zip
99037
City
Veradale
State
WA
Phone
( 509) 922-2780
18 Contact Person
License No.
VALLEF 177CG
Phone if different than above
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
15 Describe Work: Installation of Convector Supreme I insert, hearth extention
New ❑ Addition/Alteration ❑ Replace/Repair ❑
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
8 VENT: Fan(s):
Evap Cooler(s):
Hood s):
Duct(s) 1:
Miscellaneous:
10 APPLIANCE:
Dryer(s): 1
Range s):
Gas Log(s):
1 Wood Stove/
Solid Fuel:
Gas Water Heater(s):
11 UNIT HEATER(S): Wall Mount: Y N I
Floor: Y N
Suspended: Y N
12 AIR HANDLING: 10,000 CFM or less:
More than 10,000 CFM:
13 REFRIG SYSTEM BTU: 1-100M:
100-500M:
500-1000M:
14 1000-1750M:
Other:
Pressure Vessel (cu. t.):
15 COMPRESSOR/HP: Less than 3:
3-15:
15-30:
30-50:
50+:
16 GAS PIPING SYSTEM: Number of outlets:
17 HEATING SYSTEM: 1-100,000 BTU:
100,001 + BTU:
18 TYPE FUEL SOURCE: Electric ❑ ; Gas ❑ ; Oil ❑ ; Coal 0 ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air 0 ; Radiant 0 ; Heat Pump
1* Number of separate zones for any heating, A/C or air handling 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 %� J j APPLICATION J
OWNER OR \ c��,`. .i,� !. 1/t"-J'- DATE �� ! Ic. 431
Y Y