1992, 05-22 Permit App: 92003864 Heat PumpMECHANICAL PERMIT APPLICATION FORM qa; 38'b9
9y1&`1
Information Worksheet n//��
JOB STREET ADDRESS: 7' j/7091 (1/47 -62.i9 -7-7w2 / ')
CITY/STATE/ZIP:1/4/1f&4''&n1, /a. Wc266 PARCEL NUMBER:
OWNER: Pt hA,/ X Vtce s
PHONE NUMBER: %a67,-E6,%�
r
MAILING ADDRESS : f ---/K709 r/CQ_P3-,'l est a. iQ'I jo_R-Lea-it.p /L(50 ..Q99-04
,(( (Street) (City/State) (Zip)
CONTRACTOR:�L\Q.0 A0 /LGvieftitAl_cR-z& LICENSE NUMBER: SE- 1 --SG2- ±37=V-1-47--
PHONE
7=NTPHONE NUMBER: c q -/ / 7U K23414/
MAILING ADDRESS: Po 3-70-7
(Street)
%9961
(City/State) (Zip)
MECHANICAL WORKSHEET/FEE SCHEDULE
NUMBER X EACH
DESCRIPTION OF UNITS 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
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
NOTE: MINIMUM ' -..x jFEE IS $n335.00
SIGNATURE p�n_� CLA.1 0 ' $D pJ
Spokane faun • ' epartment of Building and Safety
West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675
f
x$10.00 =
x 25.00 =
x 10.00 =
x 12.00 =
x 1- i -ee- =
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 =
cLD.00)
SUBTOTAL
$ 20.00
PLUS: PROCESSING FEE
+ $ 25.00
EQUALS: TOTAL PERMIT
FEE DUE
= $ `/S°-°-
NVOICE RECAP AND DISBURSEMENT VOUCHER
STORE NO. ( O 7 9
-STORE 1C1�
No. •180843
DATE .s-aci--/o)-
CUSTOMER'S NAME
.y,
SALESCHECK
NUMBER
JOB in. 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 i
SELLING
?/..C.1.14 geIA-�3
S -al
5--(/64-/e1/
f
LI
/B3S-32'7
tiCE2
°_
f.(1109 i e O)_
Ce-tijPt P
(,cam••A
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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
TOTALS
(AUTHORIZED SIGNATURE
CHECK NO.
14489 (See Bul 0-187 Part 11 Supp. 8) REV.3/91 SEARSFORMS MANAGEMENT
V'!
(DATE)
trittat
ACCOUNTING COPY
PAYING UNIT NO
PAYING
• UNIT NAME
- (lf Different)