1990, 07-24 Permit App: 90003502 Heat PumpMECHANICAL PERMIT APPLICATION FORM
Informa ion Worksheet
JOB STREET ADDRE: -,47 . /202 �d /c -4.g_1
CITY/ST iTE/ZIP L..14 /Z1/.LPARCEL NUMBER: 1 6 `f / °
OWNER:./ PHONE NUMBER: / 9& /i
MAILING ADDRES , / !� (�c� .1 . J ' 1.-x_[_, idt o'l/
Stre it State) (Zip)
( ) y/
,/14,_,Ln /46- LICENSE NUMBER: S, '79,e -5,e -7(70//1/-7--
CONTRACTOR:
MAILING ADDRESS:
(Street)
32 7
PHONE
164 cl 9 j
(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'
TYPE II HOOD
CLOTHES DRYER
RANGE
GAS LOG
PTN. OF HOOD)
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 45, 0
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 =
NOTE:
SIGNATURE
1IMUM PE IT FEE IS $35.00
SUBTOTAL
$
PLUS: PROCESSING FEE
+ $ 25.00
EQUALS: TOTAL PERMIT
FEE DUE
$
Spokane County Department of Building and Safety
West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675
INSTALLATION INVOICE
3 7000
ay to:
Store
Date
Date paid:
N
E
DIV.
WORK
ORDER #
CUSTOMER'S
NAME
PERMIT
NO.
DATE
COMPL
INSTALLER
CHARGES
2
3
4
5
6
7
8
9
10
11
12
(FOR USE BY CASHIER)
CHECK #
TOTALS I
AMOUNT
All supporting detail must be attached.
I certify that the installations listed above have all
been completed satisfactorily in accordance with the
specifications furnished me.
(DATE)
(CONTRACTOR'S SIGNATURE)
CONTRACTOR'S INSTRUCTIONS
FOR FILLING OUT INSTALLATION INVOICE
1. In Section "A", fill in business name and mailing address in upper left-
hand box.
2 a. INVOICE FOR LABOR ONLY. Using the information on the
GOTC, complete Section "A" indicating the division, work order
number, customer's name, date of completion and charges for labor
performed.
b. INVOICE FOR MATERIAL AND LABOR.
A purchase order will be given with the GOTC for any material
you are to furnish on a job, such as: a special plenum for an
add-on air conditioner, pipe for water softeners, etc. When sub-
mitting your invoice, follow Step 2a and list your labor charges
only. On the next line, in the column titled "Work Order #", put
the letters "P.O." and the purchase order number. Indicate the
customer's name and the charges for the material supplied.
c. If you work for more than one Sears store, submit a separate
invoice for each store.
3. Total the amount of the invoice & enter opposite word `Totals'. Do
Not Enter Anything Opposite Words `Check #'.
4. Remove the #4 copy and retain for your records. This will allow you
to have a copy of all bills submitted but not paid. Attach all GOTC's
to support the entries, sign and date the invoice at the bottom of
Section "A" where indicated.
5. Submit invoice to the Installation Office to process for payment