1992, 07-17 Permit App: 92005433 Mechanical Fixturesy�35ck, aPl4 .pcSA MECHANICAL PERMIT APPLICATION FORM
2 Ir..format- on Worksheet qa 5�t3
JOB STREET ADDRESS:
CITY/STATE/ZIP:
- PARCEL NUMBER:
OWNER:,Ae/4gee, flitch
'AS4L.
MAILING ADDRESS: 7) "a / J,�2�t
,,Q- ,f94
(Street) (City/State) (Zip)
LICENSE NUMBER:
PHONE NUMBER:
PHONE NUMBER :
CONTRACTOR:
MAILING ADDRESS:
(Street)
(City/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 =
/0,00
A to
/ ' O ()
SUBTOTAL
PLUS: PROCESSING FEE
+ $ 25.00
EQUALS: TOTAL PERMIT
NOTE:MIN Mu E 5.00 FEE DUE
�4 IS$
Spoka e C s . • Department of Building and Safety
West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675
SIGNATUR
PAY TO
„, tat -
INVOICE RECAP AND DISBURSEMENT VOUCHER
STORE NO `-f 0r7q
STORE N
No. 780686
DATE 7— F
CUSTOMER'S NAME
SALESCHECK
NUMBER
JOB I.D. NO. OR
WORK ORDER NO.
AMOUNT
DUE
CONTRACTOR
ALLOCATION OF EXPENSE — FOR INSTALLATION OFFICE USE
ACCOUNT
NUMBER
DIV.
NO.
ADJUSTMENT
ACCT.
ACCT.
CONTRACTOR
EXPENSE
MEMO
SELLING
actAia 4 ad, &Jr_
5 M99e17
60 (DO
Ig.,3),?.)s?
&GIQ5
-)'1 y9,2e 11.o
car....
C i:_,T7
,r, --o,,,,_,,,,,
I certify that the installations listed above have all been
completed satisfactorily in accordance with the speci
fications furnished me.
TOTAL
AMOUNT
TOTALS
OK TO PAY PAYING UNIT NO. C7(379
(AUTHORIZED SIGNATURE)
CHECK NO
(CONTRACTOR'S SIGNATURE)
14489 (See Bul. 0-187 Part II Supp. 8) REV. 3/91 SEARS FORMS MANAGEMENT
(DATE)
ACCOUNTING COPY
PAYING
UNIT NAME
(If Different)