1992, 06-09 Permit App 92004162 Woodstove"=CHANICAL PERMIT APPLICATION FORM a` LI
lWormation Worksheet
JOB STREET ADDRESS: I 7 1 f I F S I PY214- �U
CITY/STATEOP: h� l i 0. �1 GI a / �o PARCEL NUMBER:
OWNER: �i C r�'►3 PHONE NUMBER:
MAILING ADDRESS:. �C ,
(Street) (City/Stated - (zip)CONTRACTOR: FA I n y tg reL�F-a crw f F✓( LICENSE NUMBER: F4 I C,U %C'-1-73 D LA
PHONE NUMBER:1SD41 L?jt,-89I 1
MAILING ADDRESS: 3►D ,jLpegqu SMt`AAIe' y,,F) C19;2 D&
(Street) (City/State) (zip)
._ MECHANICAL WORKSHEET/FEE SCHEDULE
I NUMBER I X EACH
MII I WORK (SEPARATE
;: <WOp13STOVEL NSER7'"x .q;'-�"h��;
GAS WATER HEATER
;GAS IrnQUPM COQ OU_BT'!3(fN(
GAS EQUIPMENT+100,000 BTU DU
T GAS ,iPIA1G (cA;O(iT '_
F. BOILER/REFRIG.1-100M BTU
60tLtER<REFRIG 501 1,000M BTU_.
ttvlLtWHEFRIG+1
'HEAT PUMP & AIR CONDIITONER 3-15 TONS
u
VENTILATING FANS
r�
Ell
TYPE I HOOD (PER 12' OR 12' PTN. OF HOOD)"
CLOTHESDRYER --
GAS LOG
OF UNITS I UNIT I =
X 10.00 a .
x25.00
X10.00 =
x12.00=.-•.
x 15.00
x 1.O0.
X 1200 =
x2000'_?.
_X2500 a;
:.X35.00. _;
x 60.60
x12.00
X 20 00 _
x 25.00
' X 35.00 �''-�`
X6000
X
x 50.001000 =--.
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 =
-:
;, Kyri <
�, �.•.�.:-; .
': k• ..,:
=-t':w� •+•: a..:r.:�
--. -
SUBTOTAL
PLUS: PROCESSING FEE 1+$ 25.00
NOTE: MINIMUM PERMIT FEE IS 535.00 EQUALS: TOTAL PERMIT
PEE DUE I = g 5D
SIGNATURE