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1992, 07-27 Permit App: 92005742 FireplaceMECHANICAL PERMIT APPLICATION FORM Information Worksheet JOB STREET ADDRESS: Z-��""' Z' A L1V$%0NcD CITY/STATE/ZIP: S? PARCEL NUMBER: OWNER: Vi "<5!5,Qj PHONE NUMBER: MAILING ADDRESS: `'�oZ-off. IS YAJA40A9Z�' S'PQ1<A-A E LJA (Street) (City/State) (Zip) CONTRACTOR: LICENSE NUMBER: ZDQ4� fie- �� t 1s 6 &L f' PHONE NUMBER: 237 QJ MAILING ADDRESS: S • (3 �'� �PD1w4,r� ..c�� . Ld 7 (Street) (City/State) (Zip) MECHANICAL WORKSHEET/FEE SCHEDULE GAS LOG MI _:..<: LN N V1= f=D-ELSWIaR~<`?; UNLISTED GAS APPLIANCE <400,000 BTU '.> USED APPLIANCE <400,000 BTU AIR HANDLER <10,000 CFM 6..+4S Guictc.ri U f7-tiE6--flee NOTE: MINIMUM PERMIT FEE IS $35.00 SIGNATURE - ". NUMBER OF UNITS X EACH UNIT =AMOUNT x 10.00 = x 25.00 = x 10.00 = x 12.00 = x 15.00 = x 1.00 = x 12.00 = x 20.00 = x 25.00 = x 35.00 = x 60.00 = x 12.00 = x 20.00 = x 25.00 = x 35.00 = x 60.00 = x 10.00 = x 10.00 = x 50.00 = x 10.00 = x 10.00 = x 10.00 = x 10.00 = x 10.00 = x 50.00 = x100.00 = x 50.00 = x100.00 = x 12.00 = x 15.00 = 1 Z. SUBTOTAL PLUS: PROCESSING FEE +$ 25.00 EQUALS: TOTAL PERMIT FEE DUE 1=$ � Spokane County Division of Buildings West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675