1992, 09-23 Permit App: 92007938 Gas Log, PipingJOB STREET ADD
CITY/STATE/ZIP:
OWNER: Li -29
MECHA `I VAL :PERMIT1:7-7:_1:31.113V.FORM
Information Worksheet
SS: 0l!
(P1 100
1,cerzwe,r, GUJ 9 Q '
\ e lt, tc.-c-A.
MAILING ADDRESS:
PARCEL NUMBER:
PHONE NUMBER: Q4-
(Street) (City/State) (Zip)
CONTRACTOR: EP- I C. i �� f Fa LICENSE NUMBER: 4- i4 I C -C' & a. i -73 b L (
MAILING ADDRESS:
DESCRIPTION
E 7
(Street)
PHONE NUMBER: (_C)q) c"t� i / /
MECHANICAL WORK
ELECTRIC/DUCTWORK (SEPARATE SYSTEMS)
WOODSTOV - lNSEfic�.:><'-':;:.:::::»>
GAS WATER HEATER
GAS EQUIPMENT<100,00fl_BTU INOLUDES
GAS EQUIPMENT +100,000 BTU DUCTWORK)
GAS. PIPING {EA OUTLET
BOILER/HEFRIG 1-100M BTU
3QILE JREF G101 1004:1BTU
BOILER/REFRIG 501-1,000M BTU
gttiktifF TIG I,0001 1,75 M B
BOILER/REFRIG +1,750M BTU ` ':
PUMP Ec AI ONDITIC
HEAT -PUMP -&-AIR CONDITIONER 3-15 TONS .
HEAT PUMPS AIR CONDITiONEF3 7
HEAT PUMP & AIR CONDITIONER 30-50 TONS
HEA3` PUMP $c AIR CONDITIONED, +50 TONS
VENTILATING FANS
EVAPORATIVE COOLERS
TYPE I HOOD (PER 12' OR 12' PTN. OF HOOD)
3YPEH
CLOTHES DRYER
RANGE
GASt6 S fD ve_
MISCELLANEOUS (NOT COVERED ELSEWHEF
UNLISTED GAS APPLIANCE <400,000 BTU
ULINSTED GAS APPLIANCE:>400 000 BTU
USED APPLIANCE <400,000 BTU
USED APPLIANCE >400,000 BTU
AIR HANDLER <10,000 CFM
AIRi4ANDLER >10.000'CFM
NOTE: MINIMUM PERMIT FEE IS $35.00
SIGNATURE
(City/State)
C (r
(Zip)
NUMBER
OF UNITS
X EACH
UNIT
= AMOUNT
x 10.00 =
x�a�
�00 =
x 10.00 =
x12.00 =
x 15.00 =
x 1.00 =
x 12.00 =
x 20.00 =
x25.00 =
x 35.00 =
x 60.00 =
x 1200 =-
x20.00 =
x25.00 =
x 35.00 =
x60.00 =
x 10.00 =
x10.00=
x 50.00 =
x 10.00 =
x 10.00 =
x10.00 =
x10.00 =
x 10.00 =
x 50.00 =
x100.00 =
x 50.00 =
x100.00 =
x 12.00 =
x 15.00 =
l
lco
_,:.
•
/0 6---(2
SUBTOTAL
$ // c�
PLUS: PROCESSING FEE
+ $ 25.00
EQUALS: TOTAL PERMIT
FEE DUE
= 5 czaLoo