1989, 11-03 Permit App: 89004514 Furnace, Piping MECHANICAL PERMIT APPLICATION FORM e-eljs#4-e-*"-g---4-'
Information Worksheet
JOB STREET ADDRESS: "Z 3 t �--
CITY/STATE/ZIP: `nom PARCEL NUMBER:
OWNER: B?.- N\u u4 PHONE NUMBER:
MAILING ADDRESS: S .')1A 1ZD_____ Lk _
(Street) (City/State) (Zip)
CONTRACTOR. ._ CENSE NUMBER: ' n#y ,q11-- iy p 257_
PHONE NUMBER:
n MAILING ADDRESS: C-L aS o r .,Q 14 `1C--qy,2,94,--,
f
(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 = C-2.)-e.
HEATING EQUIPMENT +100,000 BTU x 15.00 =
GAS PIPING (1 - 4 OUTLETS) x 4.00 =
GAS PIING (5 OR MORE. EACH: ) I x 1.00 = / Al2...--
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 =
x 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 =
t; HEAT PUMP & AIR CONDITIONER +50 TONS _ - x 60.00 =
t VENTILATING FANS x 10.00 =
;: EVAPORATIVE COOLERS x 10.00 = _
TYPE I HOOD (PER 12 ' OR 12 ' PTN. OF HOOD) x 50.00 =
,t TYPE II HOOD x 10.00 =
C CLOTHES DRYER - - - - - - - - - - - x 10.00 =
RANGE x 10.00 =
GAS LOG x 10.00 =
IMISCELLANEOUS (NOT COVERED ELSEWHERE)_ - x 10.00 =
UNLISTED GAS APPLIANCE <400,000 BTU_ - - x 50.00
UNLISTED GAS APPLIANCE >400,000 BTU_ _ _ x100.00 =
I 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
x
SUBTOTAL $ 1 3 e
PLUS: PROCESSING FEE + $ 25.00
EQUALS: TOTAL PERMIT
NOTE: M NIMUM PERMIT FEE I $35.00 FEE DUE = $ 384='--
SIGNATURE
So'-7SIGNATURE ,
a , :)
0".1,...... "..--a.. n_......s,-....a ..s n ..r 40. (... ; a., , V