1992, 02-07 Permit App: 92000691 Gas Log, Pipingon 5-b43s 1� "
,,� MECH,-..AICAL PERM "2.PPLICATION FORM
t
tQi, u't �� Z . 01 8a Information Worksheet
JOB STREET ADDRESS: • -7 05 C*t J e / 2 1
CITY/STATE/ZIP: S rpYj 1 CST'7a) a. PARCEL NUMBER:
7_
OWNER: 1°.tGI'l A %LA LOQ k i
PHONE NUMBER: q (/ "LLS.3,7
MAILING ADDRESS:
F-0
(Street) (City/State) (Zip)
CONTRACTOR: EI - ) &2DEiJ CEi.1fF✓c LICENSE NUMBER: F -4/C.0 CSC f `73 DL�t
PHONE NUMBER: (SDq) cio? -S'9 / 1
MAILING ADDRESS: E . q3)0 ..5p 2F191,C e_ ) JA 99 2 010
(City/State) (Zip)
MECHANICAL WORKSHEET/FEE SCHEDULE
DESCRIPTION
(Street)
NUMBER X EACH
OF UNITS UNIT
= AMOUNT
ELECTRIC/DUCTWORK (SEPARATE SYSTEMS
GAS WATER HEATER
.003VW:.,..�, ni 4a 12.1:1
GAS EQUIPMENT+100,000 BTU DUCTWORI
r-....vi...y.�..ww..:.+.;„w ..M,�,,.,,;w ..•. .�.-..+::..z+•.,-.i..v.'
;GA f'If' NG : i.�QUT #i`
s,M�.c+i�.+'u,.�a.,�-::::.>.ac.•,wyLL.�'w.`-a:� �i '
BOILER/REFRIG 1-100M BTU
BOILER/REF_RIG 501-1,000M
BOILER/REFRIG +1,750M BTU 1.. '" '
x 10.00 =
x 25.00 =
x 10.00 =
x12.00 =-:.
x 15.00 _:"
x 1.00
x 12.00 =
x20.00
x25.00'=
x 35.00
x 60.00
x 12.00
x 20.00
x 25.00
x 35.00
x 60.04
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 =
-..N,t,,..-,.�,..,,..,�,,:.:::;,..i,�.....,.i,:....:.:;.�....::�;Teirt-,f..xfil�,..,,.,,..;, .xis:.
HEAT PUMP & AIR CONDITIONER 3-15 TONS'--_
HEAT PUMP 8s. AIR CONDITIONER 30-50TONS : ;" "'',
reY�r�;
VENTILATING FANS_ �*
vvryvvpvwvww)N4 . ^!�^RF'31►.{.+4 a[ 3}vyv3SA�H 3w:fit•
TYPE 1 HOOD (PER 12' OR 12' PTN. OF HOOD)'
„I..
CLOTHES DRYER .-
IfriffeREMBE
GAS LOG
:MiSGE E t S (NOT. O EREi <:::::.:.:...:....
UNLISTED GAS APPLIANCE <400,000 BTU
ULI(VSTEO GAS: APPUANC400,000'BTU_€
USED APPLIANCE <400,000 BTU
USED APPLIANCE>4 ,000
AIR HANDLER <10,000 CFM
'AIRHANDLER >10,000. SFM..<?.:;:.;>:;>`
.4A-1
•
NOTE MINIMUM PERMIT FEE IS $35.00
S GNATURE
SUBTOTAL
PLUS: PROCESSING FEE
EQUALS: TOTAL PERMIT
FEE DUE
$ //
+ $ 25.00