1993, 05-18 Permit App: 93003655 ACMECHANICAL P1 MIT APPLICATION FORM
Information Worksheet
JOB STRE A D ESS: C,; I I A K. Cx
CITY/STAT � • (1 4 9(T 7 PARCEL NUMBER:
OWNER: Pb()l Y +� c2 Gt PHONE NUMBER:Y;U y 7
MAILING ADDRESS*
f (Street)
CONTRACTOR: Al 1(1 'mil ) jV-f G../`(,<� f
V
MAILING ADDRESS* t -6P�
DESCRIPTION
(Street)
(City/State) (Zip)
UCENSE NUMBER: 06'COI-1A ( 70 2 2 ,
PHONE NUMBER:
1912
(City/State)
MECHANICAL WORKSHEET/FEE SCHEDULE
ELECTRIC/DUCTWORK (SEPARATE SYSTEMS)
......................................................................................................................
WOODSTOVE/INaE1'
GAS WATER HEATER
:GAS EQUIPMENT 100,000; BTO (INCLUDES
GAS EQUIPMENT +100,000 BTU DUCTWORK)
......... ..........
GAS PIPING {EA OUTk.1 Tj::..; .
BOILER/REFRIG 1-100M BTU
BOILER/REFRIG 101>-500[uC>`BTU
BOILER/REFRIG 501-1,000M BTU
BOILERIREFRIG 1,0001-1,750M:8"
BOILER/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 COOL FIS :..:..:...:.:....:.:.`.
TYPE I HOOD (PER 12' OR 12' PTN. OF HOOD)
TYPE II H D
CLOTHES DRYER
GAS LOG
M SCELLANEOUs (NOT COVERED EL$EWHER
UNLISTED GAS APPLIANCE <400,000 BTU
UIINSTED GAS:APPIIANCE>400000 BTU
USED APPLIANCE <400,000 BTU
USED APPLIANCE >400,000 BTU
AIR HANDLER <10,000 CFM
AIR HANDLER >10,000 CFM
NOTE: MINIMUM PERMIT FEE IS $35.00
SIGNATURE
(Zip)
NUMBER
OF UNITS
X EACH
UNIT
= AMOUNT
x 10.00 =
x 25.00 =
x 10.00 =
x12.00 =
x 15.00 =
x 1.00 =
x 12.00 =
x 20.00 =
x 25.00 =
x35.00 =
x60.00 =
x 12.00 =
x20.00 =
x 25.00 =
x 35.00 =
x 60.00 =
x 10.00 =
x 10.00 =
x 50.00 =
x10.00 =
x10.00 =
x10.00=
x 10.00 =
x 1.0.00 =
x 50.tb0 =
x100.00 =
x 50.00 =
x100.00 =
x 12.00 =
x 15.00 =
----.
SUBTOTAL
$
PLUS: PROCESSING FEE
+ $ 25.00
EQUALS: TOTAL PERMIT
FEE DUE
=$ 7 G�
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