1992, 01-27 Permit App: 92000459 Woodstovea 3 MECHANICAL PERMIT APPLICATION FORM
5 Information Worksheet
JOB STREET ADDRESS: -2, `� D :2-2 ^
CITY/STATEOP: LA q�aO6
OWNER: 10a ►-e-
MAILING ADDRESS:
qa - 44 5'
PARCEL NUMBER:
PHONENUMBER:
(Street) (City/State) (Zip)
CONT9ACTOR: LICENSE NUMBER: ' cVA / 10cS
PHONENUMBER:
MAILING ADDR
L�E-Am
(Street) (Ckt /State) '
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 10.00 =
x 50.00 =
x100.00 =
x 50.00 =
x100.00 =
x 12.00 =
x 15.00 =
-
S, o�
SUBTOTAL
$
PLUS: PROCESSING FEE
+ $ 25.00
EQUALS: TOTAL PERMIT
FEE DUE
I=$ 5A 6-0
{ Spokane County Division of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675