1986, 05-30 Permit App 00011305 Woodstove, ChimneyAny F
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
Project # / r v c
O��r's Name' WQ Last First MI
C rV
Project Address (Street Name & Number)
1 eto'7 E . at-0Q et Loa_
City
are n c a r,e s
State
uJet k
ion /Plat Name
SubV4Li
Vic ADD
Assessors Parcel #
> phi'- .i — r>c--(4.
Lot
Block
Plat #
Applicant
Address
City
State
Zip
Phone
Q 2-74(Pi
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
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
15-3OHP
30-50HP
50+HP
Gas Piping
1-5 Outlets
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.
SIGNATURE OF )� APPLICATION (y/
OWNER OR II��Q DATE o�o a i0