1994, 08-17 Permit App: 94008000 ACMECHANICAL PERMIT APPLICATION FORM
Informa*n Worksheet
JOB STREET ADDRESS:_ /l , a h,l 1up-.4-
CITY/STATERIP�_�
OWNER: ti t rte %vim ii
PARCEL NUMBER:
PHONE NUMBER: 1
MAILING ADDRESS:`
(Street) (City/State)A I (zip)
CONTRACTOR: -- d LICENSE NUMBER:/�/� k.? ( �; / A
/ PHONE NUMBER: ,, <Z-1,1 � 2 �
�Isj
MAILING ADDR
(Street) (City/Stade) (7Jp)
MECHANICAL WORKSHEET/FEE SCHEDULE
NOTE: MINIMUM PERMIT FEE IS $35.00
SIGNATURE��,���
NUMBER
OF UNITS
X EACH
UNIT
-AMOUNT
x 10.00 =
x 25.00 =
x 10.00 =
x 12.00 =
x 15.00 =
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 1.0.00 =
x 50.00 =
x100.00 =
x 50.00 =
X100.00 -
x 12.00 =
x 15.00 =
_
SUBTOTAL
$
PLUS: PROCESSING FEE
+$ 25.00
EQUALS: TOTAL PERMIT
FEE DUE
=$
Spokane County Division of Buildings
West 131 'way Avenue Spokane, WA 99260 (509) 456-3675