1991, 11-15 Permit App: 91007356 Heat Pumpcr ( 36 MECHANICAL PERMIT APPLICATION FORMA-`icu
Ixiformation Worksheet
/nog 6 I
JOB STREET ADDRESS:
CITY/STATE/ZIP: »244 ) //0Q ,99(94(PARCEL NUMBER:
PHONE NUMBER: 5 3 Li - 75 Cv .S--0 5)
MAILING ADDRESS: / O O co OL Q D2 LQ : l c.7 -A 19a 1, ._
(Street) (City/State) (Zip)
9
CONTRACTOR: / - // ifi LICENSE NUMBER: ,5e- /be -sle- 3- A) V"
PHONE NUMBER: L 89 - / / 7 0 y `t ,/ v.\
OWNER: \n/1 -(Lc
MAILING ADDRESS: f)) ( 3 -7 0 7
(Street)
e_& -Le a u)q q q a9
(City/State) (Zip)
MECHANICAL WORKSHEET/FEE SCHEDULE
BER
'OF UNITS
DESCRIPTION
X EACH
UNIT
=AMOUNT
DUCTWORK SYSTEM
WOODSTOVE/INSERT
GAS WATER HEATER
HEATING EQUIPMENT <100,000 BTU
HEATING EQUIPMENT +100,000 BTU
GAS PIPING (1 - 4 OUTLETS)
GAS PIING (5 OR MORE. EACH:)
REFRIG 1-100M BTU (NOT A/C OR HEAT PUMP)
REFRIG 101-500M BTU
REFRIG 501-1,000M BTU
REFRIG 1,001-1,750M BTU
REFRIG +1,750M BTU
AIR CONDITIONER 0-3 TONS
AIR CONDITIONER 3-15 TONS
AIR CONDITIONER 15-30 TONS
AIR CONDITIONER 30-50 TONS
AIR CONDITIONER +50 TONS
FANS
HEAT PUMP &
HEAT PUMP &
HEAT PUMP &
HEAT PUMP &
HEAT PUMP &
VENTILATING
EVAPORATIVE COOLERS
TYPE I HOOD (PER 12' OR 12PTN. OF HOOD)
TYPE II HOOD
CLOTHES DRYER
RANGE
GAS LOG
MISCELLANEOUS (NOT COVERED ELSEWHERE)_
UNLISTED GAS APPLIANCE <400,000 BTU_ _
UNLISTED GAS APPLIANCE >400,000 BTU_ _
USED APPLIANCE <400,000 BTU
USED APPLIANCE >400,000 BTU
AIR HANDLER <10,000 CFM
AIR HANDLER >10,000 CFM
x$10.00 =
x 25.00 =
x 10.00 =
x 12.00 =
x
x 1.00 =
x 12.00 =
x 20.00 =
x 25.00 =
x 35.00 =
x 60.00 =
x 12.00 =
x 20.00 =
x 25.00 =
x 35.00 =
x 60.00 =
x 10.00 =
x 10.00 =
x 50.00 =
x 10.00 =
x 10.00 =
x 10.00 =
x 10.00 =
x 10.00 =
x 50.00 =
x100.00 =
x 50.00 =
x100.00 =
x 12.00 =
x 15.00 =
00
NOTE: MINIM
SIGNATURE Ck.r1R!
T FEE IS $35.00
Spoka e C
West 1303 Broad
SUBTOTAL
$ . co
PLUS: PROCESSING FEE
+ $ 25.00
EQUALS: TOTAL PERMIT
FEE DUE
=$3?
Department of Building and Safety
y Avenue Spokane, WA 99260 (509) 456-3675
r u�uVOICE RECAP AND DISBURSEMENT VOUCHER
PAY TO/ .Yf r;C�`7/
(1
STORE NO. %/t9 .f j
STORE
No. 381824
DATE '
ALLOCATION OF EXPENSE — FOR INSTALLATION OFFICE USE
4
I certify that the installations listed above have all been
completed satisfactorily in accordance with the speci
fications furnished me.
(CONTRACTOR'S SIGNATURE)
TOTAL
AMOUNT
OK TO PAY
CHECK NO.
TOTALS
(AUTHORIZED SIGNATU
PAYING UNIT
14489 (See Bul. 0-187 Part 11 Supp. 8) REV. 3/91 SEARS FORMS MANAGEMENT
PAYING
--UNIT NAME
(/f Different)
CONTRACTOR'S FILE COPY