1984, 09-26 Permit App 00002523 Wood StoveMECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1
_
Owner's Name (Last)
S Q
(First)
(M)Department
Use Only
Project No.
2 Project Address IN Mailling Address)
S
Space Zip
3
City/Community
S -pJ
I State
1 W"I "'
Subdivision/ Plat Name
4
Assessor P(,ar I No.
Lot
Block
16
Contractor Firm Name
/
Street Address ! "V
G
17
Zip
City
State
Phone
18 Contact Person
��V w L A
License No. 2
LL/VSA/ / �/� g
Phone if different than above
8
Owner/Agent (If different than N1 above)
Business Address
g
Zip
City
State
phone
15
Describe Work:
New ❑
Addition/Alteration
❑ Replace/Repair ❑
10
Applicant Name
Street Address
11
Zip
City
State
Phone
8
VENT: Fan Is):
Evap Cooler(s):
Hood (a):
Duct(s)1:
Miscellaneous:
10
APPLIANCE:
Dryer(s):
Range(s):
Gas
Log(s):
Wood Stove/
Solid Fuel:
Gas Water Heater(s):
11
UNIT HEATER(S): Wall Mount: Y N
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:
100-50OM:
500-1000M:
14
1000-175OM:
Other:
Pressure Vessel (cu. ft.):
15
COMPRESSOR/HP: Less than 3:
3-15:
15-30:
30-50:
50+:
16
GAS PI PING SYSTEM: Number of outlets:
17
HEATING SYSTEM: 1-100,000 BTU:
100,001 + BTU:
18
TYPE FUEL SOURCE: Electric ❑
Gas ❑ Oil ❑
Coal ❑ Wood ❑ Solar ❑
19
TYPE DISTRIBUTION: Forced Air
❑ ; Radiant ❑
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 APPLICATION
OWNER OR DATE