1992, 07-16 Permit App: 92005678 Mechanical FixturesMECHANICAL PERMIT APPLICATION FORM
( Nou(�-Qin Vw q41,la 1-705 Irformation Worksheet a- 5(078
JOB STREET ADDRESS: ;.(�/.� e , yW03 --
CITY/STATE/ZIP " PARCEL NUMBER:
OWNER: I/ / , y� /�,
• ���% ('. ,n_.��1%h � PHONE NUMBER:
MAILING ADDRESS: .�� /� ./�Li /�� _kk&Z9z,
Street) (City/State) fZipt
CONTRACTOR:. LICENSE NUMBER: h-Slc?
PHONE NUMBER:
MAILING ADDRESS: -404 ,�%�'%
(Street) City/State) (Zip)
MECHANICAL WORKSHEET/FEE SCHEDULE
NUMBE RX EACH I
DESCRIPTION I OF UNITS I 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 B-
TU
REFRIG 1,001-1,750M BTU
REFRIG+1,750M BTU___________
HEAT PUMP & AIR CONDITIONER 0-3 TONS _ _
HEAT PUMP & AIR CONDITIONER 3-15 TONS _
HEAT PUMP & AIR CONDITIONER 15-30 TONS _
HEAT PUMP & AIR CONDITIONER 30-50 TONS _
HEAT PUMP & AIR CONDITIONER +50 TONS
VENTILATING FANS
- - - - - - - - - -
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
TU
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 =
i x 1;.;'� =
x 1.00 =
x 12.00 =
x 20.00 =
x 25.00 =
x 35.00 =
x 60.00 =
x 12.00 =,Q
x 20.00 =
x 25.00 =
x 35.00 =
x 60.00 =
x 10.00 =
x 10.00 I
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 =
SUBTOTAL
PLUS: PROCESSING FEEI+ $ 25.00
I
EQUALS: TOTAL PERMIT
NOTE: IN P FEE IS $35.00 FEE DUE = $
SIGNATURE
Spoka C Department of Building and Safet
West 1303 Broadway Avenue Spokane, WA 99260 (5a9) 456-3675
PAY TOC- „ ^��� RECAP AND DISBURSEMENT VOUCHER
67
'"'� O_ A� �/�i�O i�
STORE NO. �/
STORE. �-
No. 780698
DATE -4?cQ -
CUSTOMER'S NAME
SALESCHECK
NUMBER
JOB I.D. NO. OR
WORK ORDER R
AMOUNT
DUE
CONTRACTOR
ALLOCATION OF EXPENSE - FOR INSTALLATION OFFICE USE
ACCOUNT
NUMBER
DIV.
NO.
ADJUSTMENT
ACCT.
ACCT.
CONTRACTOR
EXPENSE
MEMO
SELLING
J�i�
� ' ✓
s
I certlty tnat the Installations listed above nave all been
completed satisfactorily in accordance with the speci
fications furnished me.
(CONTRACTOR'S SIGNATURE)
TOTAL
AMOUNT�3TOTALS
OK TO PAY
CHECK NO.
(AUTHORIZED SIGNATURE)
(DATE)
14489 (See Bul. 0-187 Part II Supp. 8) REV. 3/91 SEARS FORMS MANAGEMENT
ACCOUNTING COPY
PAYING UNIT NO.
PAYING
UNIT NAME
(ff Different)