1991, 12-05 Permit App: 91008411 Water Heater ; LA 3O 1 MECHANICAL PERMIT*APPLICATION FORM
A0 9p-2k Information WorksheetI - e 1 ' 7 ��-
JOB STREET ADDRESS: --7/;;RV // /
CITY/STATE/ZIP: 4 d1 / 4p l leigq9_/� PARCEL NUMBER: CLe(x N C . dRcy((
OWNER: /06/1 ,(0, r)-),1��� C/t� PHONE NUMBER: 94471 -- 1937
MAILING ADDRESS: 7 / J-( £ / / Nj ,I ii /I/ ( (�Q�sl-q9J�9
(Street) City/State) (Zip)
CONTRACTOR: AO" (0 C«1�Jiy/,� LICENSE NUMBER: S2. ,/4/Q--S i2 7a.4)/
PHONE NUMBER: (.4K1-//7 Y3 57
MAILING ADDRESS: y9( ) 3`70 7 'a (/ , (1 )4 99 o
(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 = /0 , 00
HEATING EQUIPMENT <100, 000 BTU x 12. 00 =
HEATING EQUIPMENT +100, 000 BTU x 1 .4919 =
GAS PIPING (1 - .4 OUTLETS) x
GAS PIRING (5 OR MORE. EACH: ) x 1. 00 =
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 =
HEAT PUMP & AIR CONDITIONER 3-15 TONSx 20. 00 =
_
HEAT PUMP & AIR CONDITIONER 15-30 TONS _ x 25. 00 =
HEAT PUMP & AIR CONDITIONER 30-50 TONS _ x 35. 00 =
HEAT PUMP & AIR CONDITIONER +50 TONS _ _ x 60. 00 =
VENTILATING FANS x 10. 00 =
EVAPORATIVE COOLERS x 10. 00 =
TYPE I HOOD (PER 12 ' OR 12 ' PTN. OF HOOD) x 30. 00 =
TYPE II HOOD x 10. 00 =
CLOTHES DRYER x 10. 00 =
RANGE x 10. 00 =
GAS LOG x 10. 00 =
MISCELLANEOUS (NOT COVERED ELSEWHERE)_ x 10. 00 =
UNLISTED GAS APPLIANCE <400, 000 BTU_ _ _ x 50. 00 =
UNLISTED GAS APPLIANCE >400, 000 BTU _ x100. 00 =
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 =
SUBTOTAL $ /Q 41a
PLUS: PROCESSING FEE + $ 25 . 00
EQUALS: TOTAL PERMIT^
NOTE: INIHUM '4i�j FEE IS $35.00 FEE DUE = $ 35
SIGNATURE ( 4)/1V?#/ ' , / /(,1Jd
41,
Spokan - Co I Department of Building and Safety
West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675
INVOICE AND INSTALLER RECAP SHEET
(INSTALLER TO ATTACH JOB DETAIL-LABOR PRICING WORKSHEET
INSTALLER AND THE CERTIFICATE OF COMPLETION-TO THIS RECAP) PAGE OF
INSTALLATION OFFICE UNIT NO. ,r DATE „./7�!f ./.1e7/
— NOTE: If the Installation office unit �-7
number is different than the SELLING UNIT NO. H) _`0 CHECK NO.
selling unit number, the total
dollar amount is to be atm'd (../. ...._
,
to the selling unit. DIV.NO. 7 AMOUNT$
FED.I.D.#
WORKORDER OR SOLD UNSOLD LABOR UNSOLD LABOR INSTALL INSTALL MATERIALS TOTAL TOTAL TOTAL
CUSTOMER NAME SALESCHECK NO. LABOR DUE TO DUE TO WHSE DELIVERY& SUPPLIED COST SELL M/U%
PRODUCT ERROR INSTALL ERROR CHGES HOLING CHGES
i.)P7 All'1ltPAlA AR /q//,- ,. ,
tit L7
•a
* d -F
}).227(..,. .
TOTAL $_%�`x!=' ' $ $ $ $ $ $ $ $ .:.3.e.: 2--
$'.)5
li ACCT. ACCT. ACCT. ACCT. ACCT. ACCT. ACCT. ACCT. — — / —
187-04-000 103-00-000 187-08-000 140-87-001 116-87-000 105-01-000 — — —
14613(2/91) STORE
Sears Forms Management ,