1995, 03-28 Permit App: 95001782 Gas Log, Piping • MECHANICAL PERM'.r APPLICATION FORM �(
Information Worksheet t U
JOB STREET ADDRESS: 5. )/n / AI 7 �t ►yr���, , L��
CITY/STATE/ZIP: f��,n, nP (ilk. �,�a L PARCEL NUMBER:
OWNER:: 2� �� / PHONE NUMBER: ? -
MAILING ADDRESS:
(Street) (City/State) (Zip)
CONTRACTOR: /11 try=-r, /J p,-T - -', LICENSE NUMBER:N D I@ 6i I✓ A 0 7 6 L
PHONE NUMBER: 5 3 <j/- y 7_S
MAILING ADDRESS: F _ ',td--it:n A ( c.' 97 /,_
(Street) (City/State) (Zip)
MECHANICAL WORKSHEET/FEE SCHEDULE
NUMBER X EACH
DESCRIPTION OF UNITS UNIT =AMOUNT
ELECTRIC/DUCTWORK(SEPARATE SYSTEMS) x 10.00 =
WOODSTOVF INSERT.. x 25.00 =
GAS WATER HEATER x 10.00 =
SAS EQUIPMENT<100,000►BTU(INCLUDE :>>> x 12.00 =
• GAS EQUIPMENT+100,000 BTU DUCTWORK) x 15.00 =
I
x 1.00 = /, a n
BOILER/REFRIG 1-100M BTU x 12.00 =
x 20.00 =
.............
BOILER/REFRIG 501-1,000M BTU x 25.00 =
x 35.00 =
BOILER/REFRIG +1,750M BTU x 60.00 =
................
HEAT PUMP&AIR J►NDITIONER 0 3 TONS x 12.00 =
HEAT PUMP&AIR CONDITIONER 3-15 TONS x 20.00 =
HEAT`I MP All CONDITI± NEI 15 30 TANS :: x 25.00 =
HEAT PUMP&AIR CONDITIONER 30-50 TONS x 35.00 =
x 60.00 =
VENTILATING FANS x 10.00 =
E. A
......... ................... ... .............. x 10.00
TYPE I HOOD (PER 12' OR 12' PTN. OF HOOD) x 50.00 =
TYPE II HOOD.::.:..:::::::::..::.:>>`:«>><>>: x 10.00 = .
. ....................................
CLOTHES DRYER x 10.00 =
x 10.00 =
GAS LOG x 10.00 = ) ® , a
.............
MISCELLANEOUS(NOT COVERED ELSEWH RE ><:> x 10.00 =
UNLISTED GAS APPLIANCE<400,000 BTU x 50.b0 =
ULINSTED GAS APPLIANC 00, t 0 BTU'>:; : ;: ''`'';`" x100.00=
USED APPLIANCE<400,000 BTU x 50.00 =
x100.00=
AIR HANDLER<10,000 CFM x 12.00 =
x 15.00 =
SUBTOTAL $ //, p p
PLUS: PROCESSING FEE +$ 25.00
NOTE: MINIMUM PERMIT FEE IS$35.00 EQUALS: TOTAL PERMIT
FEE DUE = - 0 4
SIGNATURE �� _ - �1
Spokane County Division of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675