1991, 10-23 Permit App: 91007118 Wood StoveMECHANICAL PERMIT APPLICATION FORM
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Information Worksheet
JOB STREET ADDRESS: ) 3a l Lem 1 /1{•/I
CIMSTATEIZIP: S n01C QR L) (o PARCEL NUMBER:
OWNER: OO PHONENUMBER: Qzq-gs/,e
MAILING ADDRESS: IIeAi /,��
(Street) (City/State) PIP)
CONTRACTOR: rOICs &RQDE.A1 CEAI%f✓[- LICENSENUMBER: F41COOC-1-73D1.(
PHONE NUMBER: (SDg) qJt,-8911
MAILINGADDRESS: E Q)Q Spe0jLkE, S.�KAAe- WR 9920(0
(Street) (ciy/state) (Lip)
._ MECHANICAL WORKSHEET/FEE SCHEDULE
NUMBER I X EACH
DESCRIPTION OF UNITS UNIT =AMOUNT
GAS EQUIPMENT +100.000 BTU
BTU
�9,�),L �EP#UCOOOj #i31G>#
BOILERIREFRIG+1,750M BTU tri.
MP Vl C -DWEfi
HEAT PUMP & AIR CONDITIONER
' HEAT PUMP & AIR CONDITIONER
Ata�Q�� yr E
VENTILATING FANS
& At30 A'ilf"TEsTCFF�Oi£E33
TYPE I HOOD fPER 12' OR 12' PTD
MISCELLANEOUS (NOT COVERED ELSEWHERE
UNLISTED (;Ac APPLIANCE <400.000 STU
giUfISTED GAS APPLIANC04�' *000 BTU
USED APPLIANCE <400,000 BTU
`l1SEpAPPLIANCE>C0000._6U :�9"2`';.
AIR HANDLER <10,000 CFM
NDLER>10,000CFM;
NOTE: MINIMUM PERMIT FEE IS $35.00
SIGNATURE
Hookane Court'- ,ior of Buil r-
x 10.00 -
x25.00 =
x 10.00 =
x 12.00 =
x 15.00 =
x 1.00 =
X12.00 ='
x 20.00 ,-
X25.00 -
x 35.00
x 60.00
x12.00
x 20.00 =
x 25.00
x 35.00 =
x60.00=
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 -
Y -
Z 5 -
-
..<n«t
--,
'SUBTOTAL
S2.5 -
t PLUS: PROCESSING FEE
+ $ 25.00
EQUALS: TOTAL PERMIT
FEE DUE
ot)
Ls SD
SIGNATURE
Hookane Court'- ,ior of Buil r-