re-2011-00066_0004.jpg MECHANICAL PERMIT APPLICATION
Jurisdiction of City of Blair, Nebraska
218 South 16 Street
Blair, Nebraska 68008
Fax (402) 426 -4195 M 2031
(402) 426 -4191
Application Date: Permit Fee: $
Job Address
Owner Mail Address Zip Phone
1.
Contractor Mail Address Zip Phone
2.
3. Class of Work: O COMMERCIAL O RESIDENTIAL O New O Addition O Alteration O Repair O Replacement
Describe Work:
4.
MECHANICAL PERMIT FEES
Heat Pump Tons
Central A/C Tons Furnace /Heat Pump /Air Conditioner (Per Unit)
Furnace BTU /H Up to and including 100,000 BTU / 3Ton ... .........................$15.00
# of Units A/C Furnace/Heat Pump /Air Conditioner (Per Unit)
Furnace
Over 100,000 BTU / 3 Ton .................... .........................$
Completion Date: Refrigeration Units /Coolers/Lines /Compressor — Commercial
Boiler Chart (New or Replacement) (Per Unit)
... .........................$15.00
BTU Fee
..................................................
Up to 100, 000 ....... .........................$
100,000 - 500, 000 ..... .........................$30.0 G as 0 F2 Fite o e- W v a e
500,000 -1, 000 ,000 ........................... $40.00
1, 000, 000 -1, 750, 000 ........................$60.00 Boiler (use BTU Chart to left)
Over 1, 750 ,000 .......................... ...$100.00 pp
A liance Vent / Fans ........................$10.00
Notice
Duct System ......... .........................$
I hereby certify that I have read and examined this
application and know the same to be true and correct. All Gas /Air Outlets .................First 5 x $6.00
provisions of laws and ordinances governing this type of
work will be complied with whether specified hcrcin or
not. The granting of a permit does not presume to give Additional x $1.00
authority to violate or cancel the provisions of any other
state or local law regulating construction or the Radiant Heat Systems /Gas/Water
performance of construction. Piping System ....... .........................$50.
Modular Home ............................... $50.00
Signature of Contractor or Authorized Agent
Permit Issuance Fee . .........................$25.00
Total
Date Current License on File O Yes O No O N/A
Comment:
WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
Approved By:
Rev. 2008 -10