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