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<br />-- <br /> <br /> <br />Det.aiied descri!Jtiol1 of work: <br /> <br />P!e:lI~e check all boxes th<1t apply! <br />O_AJC <br />o Boiler <br />o Air to Air exchango:r <br />o CI.., 1 Hood <br />o Oth" <br /> <br />o Class II Hood <br />o CombustlDn Air <br />o Dryer Venting <br />o Duct work <br /> <br />o Fire? lace <br />o Furnat:e <br />o Heat Pump Applianc!! <br />o Pool He.", <br /> <br />o R.:1d.iant HC:!ater <br />g Refrigeration <br />o Solar . <br />o Unit Heater <br /> <br />Fill ill the appropriate boxes below: <br />Make Model # <br /> <br />Heat Fuel <br />LossiGain <br />-, <br />I <br /> <br />Flue <br />Dia.meter <br /> <br />Input <br />(BTUJ <br /> <br />CFM <br /> <br />lons <br /> <br />Hp <br /> <br />f <br /> <br />I <br /> <br />Gas piping <br /> <br />Please check all boxes that appiy! <br />o Boile, 0 F~epl." <br />o Dryer 0 Furnace <br /> <br />o G., Main <br />ORange <br /> <br />o Unit Heater <br />o Other <br /> <br />..-- <br /> <br />I <br />i <br />i <br />J <br /> <br />If gas pLping will be done by others indicate: Na.me <br />Address <br />Which appliances <br /> <br />St.a.te M~cha..n.ical Bob.d # <br /> <br />Phone #. <br /> <br />o Please check if on flie <br /> <br />All Fees are based on valuation. i.ccludlng cost of labor a.nd ,[1laterials. <br />The nliniruum fee is $45.00 + .5tate surcharge. TOT.JJ. JOB ''Y'"...-\LUAT10N: $ <br /> <br />. 00 <br />16 I :?CJ5':- <br />, <br /> <br />PERMIT FEE <br />SURCF_'.RGE <br /> <br />1.,15".1. 0 g <br />1 'S,yc <br />~.'I3 <br /> <br />(1 1,.;%-ofTotal Job Valuation - minimum of $45.00) <br />(.0005 ~ Total Job Valuation - minimum. $.50) <br /> <br /> <br />TOTAL DUE <br /> <br />NA.>.1E OF APPLICANT <br />Pi.I!ase iJ'pftor p,rint <br /> <br />DATEA:1u4 - SO - 2()O ( <br /> <br />..--.-...------.. <br /> <br />,c::rn.N .:\:T'Tif.1P ();' <br /> <br />~----- <br /> <br />___......o'_____ <br />