1993, 05-12 Permit App: 93003441 Water Heater45195-03/0
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MECHANICAL PERMIT APPLICATION FORM
Information Worksheet
JOB STREET ADDRESS: S • ,1.\007 OGS-tto
CITY/STATE/ZIP: SQtM't4 1t Warr 9/7-1 7- PARCEL NUMBER:
OWNER: BR_\ A -t . i-tiorWI t 7eJN PHONE NUMBER:
MAILING ADDRESS:
(Street)
CONTRACTOR:b» VC 6f COM -C11.01..-
MAILING ADDRESS: (J • 1 15 MA-Ot2A-1 A
(Street)
MECHANICAL WORK
DESCRIPTION
ELECTRIC/DUCTWORK (SEPARATE SYSTEMS)
GAS WATER HEATER
GAS'tbDIf MOUE£ S1t) p717E{IKlOW I K&
GAS EQUIPMENT+100,000 BTU DUCTWORK)
GAS,p>P.Ih1G (EAOUT ;ETj=:` RA tit'
BOILER/REFRIG 1-100M BTU_
ia
BOILER/REFRIG 501-1,000M BTU
BOILER/REFRIG +1,750M BTU
HEAT PUMP & AIR CONDITIONER 3-15 TONS
b
tar
HEAT PUMP & AIR CONDITIONER 30-50 TONS
HEA7'E311SCONpiTlSORt45 TONS
VENTILATING FANS
' ./ f'ARA7fSl CQp. SFTCP swan
TYPE I HOOD (PER 12' OR 12' PTN. OF HOOD)
i"f`1CPE:1(1Hgl7D::Py.�x,�";tt�;,�..
CLOTHES DRYER
M•
GAS LOG
MISE VEKOI7SC, IPOV R p C�% VJH id
UNLISTED GAS APPLIANCE <400,000 BTU
14I0014p GAs A L4iiiCgrgg (w Tl1 i
USED APPLIANCE <400,000 BTU
;USED ApPL1ANG U17;UQat a. xs
AIR HANDLER <10,000 CFM
`A1iP1ANp11,APIUT000CFM"f
NOTE: MINIMUM PERMIT FEE $35M0
SIGNATURE
(City/State) (Zip)
LICENSE NUMBER:b t VC -0 E -C 1$$ LL
PHONE NUMBER:
Sk>Kv1+- t '.4/A 9 S2,02,
(City/State) (Zip)
NUMBER
OF UNITS
X EACH
UNIT
= AMOUNT
x 10.00 =
x25.00 =
t
x10.00 =
(,d
x 12.00 =
x 15.00 =
x 1.00 =
x 12.00 =
x 20.00 =
x25.00 =
x 35:00 =
x 60.00 =,
x12.00 =
x 20.00 =
x25.00 =
x 35.00 =
x 60.00 =
x 10.00 =
x 10.00 =
x50.00 =
x10.00 =
x10.00 =
x10.00 =
x 10.00 =
x10.00 =
x 50.00 =
x100.00 =
at
3.
x 50.00 =
x100.00 =
x 12.00 =
x;
x 15.00 =
SUBTOTAL
$ l0
PLUS: PROCESSING FEE
+ $ 25.00
EQUALS: TOTAL PERMIT -
FEE DUE
oo
= $ 35