1990, 08-06 Permit App: 90003762 AC MECHANICAL PERMIT APPLICATION FORM v,-e AiA
Information Wb1sheet 1s
JOB STREET ADDRE' //47/7;7' //jj7_'C�
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CITY/SATE/ZIP a 1,___L,40-69, '4 /ate • PARCEL NUMBER:
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OWNER: *v . 1 mac/_ PHONE NUMBE %� -o,6
MAILING ADD* " - ,/,:20/ \ / a)/// • 9),e,... ! •
(Street City/Stat) (Zip)
CONTRACTOR: 41` 1_- 1/ ' LICENSE NUMBER: �/ -,47,E'-S/* : 7 A7
PHONE NUMB;`R: , (1 -//7.6 )(4&
MAILING ADDRESS: -L 'i • x- 70 7 i1 L-P„� 71,
• (Street) " (City/State) (Zip)
MECHANICAL WORKSHEET/FEE SCHEDULE
NUMBER X EACH
DESCRIPTION OF UNITS UNIT = AMOUNT
DUCTWORK SYSTEM x$10.00 =
WOODSTOVE/INSERT x 25.00 =
GAS WATER HEATER x 10.00 =
HEATING EQUIPMENT <100, 000 BTU x 12.00 =
HEATING EQUIPMENT +100,000 BTU x 15/
GAS PIPING (1 - 4 OUTLETS) x = _
GAS PI4ING (5 OR MORE. EACH: ) x 1.00 =
REFRIG 1-100M BTU (NOT A/C OR HEAT PUMP) x 12. 00 =
REFRIG 101-500M BTU x 20.00 =
REFRIG 501-1,000M BTU x 25. 00 =
REFRIG 1,001-1,750M BTU x 35. 00 =
REFRIG +1,750M BTU x 60.00 =
HEAT PUMP & AIR CONDITIONER 0-3 TONS _ _ / x 12.00 = //a
HEAT PUMP & AIR CONDITIONER 3-15 TONS _ x 20.00 =
HEAT PUMP & AIR CONDITIONER 15-30 TONS _ x 25. 00 =
HEAT PUMP & AIR CONDITIONER 30-50 TONS _ x 35. 00 =
HEAT PUMP & AIR CONDITIONER +50 TONS _ x 60. 00 =
VENTILATING FANS x 10. 00 =
EVAPORATIVE COOLERS_ x 10. 00 =
TYPE I HOOD (PER 12 ' OR 12 ' PTN. OF HOOD) x 50. 00 =
TYPE II HOOD x 10. 00 =
CLOTHES DRYER x 10.00 =
RANGE x 10. 00 =
GAS LOG x 10. 00 =
MISCELLANEOUS (NOT COVERED ELSEWHERE)_ _ x 10. 00 =
UNLISTED GAS APPLIANCE <400,000 BTU_ _ _ x 50.00 =
UNLISTED GAS APPLIANCE >400,000 BTU _ _ x100.00 =
USED APPLIANCE <400,000 BTU x 50. 00 =
USED APPLIANCE >400,000 BTU x100. 00 =
AIR HANDLER <10,000 CFM x 12 . 00 =
AIR HANDLER >10, 000 CFM x 15. 00 =
SUBTOTAL $ /4 .df---
PLUS:
�PLUS: PROCESSING FEE + $ 25. 00
I EQUALS: TOTAL PERMIT
NOTE: I MUM PE IT- FEE IS $35.00 FEE DUE = $ Ll-f /- -1
SIGNATURE kti_e ,1
Spokane County Department of Building and Safety
West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675
3.CONTRACTOR'S RECEIPT INSTALLATION INVOICE "
(7)
346703
Pay to: // Date paid:
Store
Date
L
WORK CUSTOMER'S PERMIT DATE INSTALLER
N DIV. ORDER# NAME NO. COMPL CHARGES
CONTRACTOR'S INSTRUCTIONS
1
, ) _ FOR FILLING OUT INSTALLATION INVOICE
2 r /-177-1.74' 1. In Section "A", fill in business name and mailing address in upper left-
3 hand box.
4 2. a. INVOICE FOR LABOR ONLY. Using the information on the
5 GOTC, complete Section "A" indicating the division, work order
6 number, customer's name, date of completion and charges for labor
7 performed.
8 b. INVOICE FOR MATERIAL AND LABOR.
941. 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
10 M.y
add-on air conditioner, pipe for water softeners, etc. When sub-
11 mitting your invoice, follow Step 2a and list your labor charges
12 ' only. On the next line, in the column titled "Work Order #", put
TOTALS I • the letters "P.O" and the purchase order number. Indicate the
(FOR USE BY CASHIER) AMOUNT customer's name and the charges for the material supplied.
c. If you work for more than one Sears store, submit a separate
CHECK#
invoice for each store.
All supporting detail must be attached. 3. Total the amount of the invoice & enter opposite word `Totals'. Do
Not Enter Anything Opposite Words `Check #'.
I certify that the installations listed above have all 4. Remove the #4 copy and retain for your records. This will allow you
been completed satisfactorily in accordance with the to have a copyof all bills submitted but not paid. Attach all GOTC's
specifications furnished me.
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
,, /
(DATE) (CONTRACTOR'S SIGNATURE)
15400 REV.10-89(INSTRUCTIONS FOR CONTRACTOR PRINTED ON 3RD COPY)