1985, 07-01 Permit App 00006183 2 Woodstoves/5186
MECHANICAL PERMIT APPLICATION WORKSHEET /10-e,
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project N et.,, /f1
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Owner's Name Last First MI
•5K 0 (\i v. .1) ei \-- S '
Project Address (Street Name & Number)
E. k `1.'-1 L, B R O A ►3 W A Le
City State
Cc, ilZc_ctv ra c...y S ‘,.1 H S 1i
Subdivision / Plat Name
C. t J i 8 i N hno i t 10 N
Assessors Parcel M
/ — C225
Lot
`�
Block /
Plat #
Applicant
Address
City
State
Zip
Phone
q 9 — 39 `i
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
/'i7 ',
Air Handling Units
0-10,000 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-30HP
30-SOHP
50+HP
Gas Piping
1-5Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
10‘,;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.
SIGNATUR. OF
OWNER OR v Uk4-04
APPLICATION
DATE