1992, 02-20 Permit App: 92000918 Mechanical FixturesOa5y1-,0-4,., MECHANICAL PERMIT APPLICATION FORM
2(07) Ir. formation Worksheet
JOB STREET ADDRESS: �) (/17 / A..077412_ /�� , l0 1 LA"a(cle , ,.
CITY/STATE/ZIP:
OWNER:
Qi W 4 PARCEL NUMBER:
MAILING ADDRESS : Y74 tILtiv2 <2 /ze,
(Street)
CONTRACTOR: k4PaVi.Q, /f, 1. yt
PHONE NUMBER: 9 /0
MAILING ADDRESS: /966, 311/9/7
(Street)
2 x1,0,4 -rte , //I? Q ?/b
City/State) (Zip)
LICENSE NUMBER: SE - -ie - Lck --
PHONE NUMBER: z/89-//7 X , ,‘
�tCity/State) (Zip)
MECHANICAL WORKSHEET/FEE SCHEDULE
NUMBER X EACH
OF UNITS UNIT
DESCRIPTION
=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
HEAT PUMP &
HEAT PUMP &
HEAT PUMP &
HEAT PUMP &
HEAT PUMP &
VENTILATING
AIR CONDITIONER
AIR CONDITIONER
AIR CONDITIONER
AIR CONDITIONER
AIR CONDITIONER
FANS
0-3 TONS _
3-15 TONS
15-30 TONS
30-50 TONS
+50 TONS
EVAPORATIVE COOLERS
TYPE I HOOD (PER 12' OR 12' PTN. 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 1
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,', PEN IT FEE IS $35.00
SIGNATURE �(�0 aL� e 44O
Spoka e Co6ty Department of Building and Safety
West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675
SUBTOTAL
PLUS: PROCESSING FEE
+ $ 25.00
EQUALS: TOTAL PERMIT
FEE DUE
=$t9
INVOICE RECAP AND DISEIJRSEMENT VOUCHER
PZ'e•r
CUSTOMER'S NAME
SALESCHECK
NUMBER
Or ab 7
I certify that the insta a ions listed above have all been
completed satisfactorily in accordance with the speci
fications furnished me.
(CONTRACTOR'S SIGNATURE)
STORE NO. VOW'
STORE - J
JOB I.D. NO. OR
WORK ORDER NO.
TOTAL
AMOUNT
AMOUNT
DUE
CONTRACTOR
No. 463507
DATE _‘2_17.45.7s.
ACCOUNT
-49.
ALLOCATION OF EXPENSE — FOR INSTALLATION OFFICE USE
ACCOUNT
NUMBER
DIV.
NO. ADJUSTMENT ACCT.
ACCT.
CONTRACTOR MEMO
EXPENSE SELLING
•
:J Ttib4,;l�:<ito51Y
rte` 1 ti
!!1715,1...
i•► i� �.�_.1.4 .'
.r.,^wip
TOTALS
OK TO PAY
(AUTHORIZED SIGNATURE)
CHECK NO c7/�- 2•
14489 (See Bul. 0-187 Part 11 Supp. 8) REV. 3/91 SEARS FORMS MANAGEMENT
(DATE)
CONTRACTOR'S BILLING COPY
PAYING UNIT NO.
,. •y...��,. ,. y,. e.�.
N � �• .� Vii: �,] N _ . �• � ��
S'
• •. S� a� ' • .•�
N;
r Z
ori G'• o
7
7I
PAYING
UNIT NAME
(If Different)