AD-2012-00478_0002.tif • j
MECHANICAL PERMIT APPLICATION
Jurisdiction of City of Blair, Nebraska
• 218 South 16� Street j
Blair, Nebraska 68008
Fax (402) 426 -4195 M'2 ®31
(402) 426 -4191
Permit Fee: $
Application Date:
Job Address, ' C
Zip Phone
Owner Mail Address
1. • Zip
Phone
Contractor Mail Address k
2.
3. Class of Work: O COMMERCIAL O RESIDENTIAL O New O Addition [I Alteratio O Repair O Replacement
Describe Work:
4. MECHANICAL PERMIT FEES
Tons /
Heat Pump � � r [
Tons Furnace/Heat Pump /Air Conditioner (Per Unit) 5 00
Furnace BTU/H j
Central A/C ...........$1
Up to and including 100,000 BTU / 3Ton ................. ;
A/C Fumace/Heat Pump /Air Conditioner (Per Unit) $25.00
# of Units
Furnace Over 100,000 BTU / 3 Ton ......... ............................... ....
Completion Date: Refrigeration Units /Coolers/Lines /Compressor — Commercial
(New or Replacement) (Per Unit) $15.00
BoilerChart ...................................... ...............................
BTU Fee
Up to 100, 000 ....... .........................$15.00 G �� (� d�. ca 4 W 6 a
100, 000 -500, 000 ..... ......:..................$30.00
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 t
Appliance Ven ans.:........
.......$10.00 t'
Notice Duct System ......... .........................$
I hereby certify that I have read and examined this
application and know the same to be true and correct. All Gas /Air O ................ First 5 x $6.00
provisions of laws and ordinances governing this type of
work will be complied with whether specified herein or ,,.,.,,,Additional x$1.00
not. The granting of a permit does not presume to give
authority to violate or cancel the provisions of any other
state or local law regulating construction or the Radiant Heat Systems /Gas/Water $50.00
performance of construction. Piping System .......................
Modular ............................... $50.00
Signature of Contractor or Authorized Agent 25.00
' •. Permit Issuance Fee ...................... •,, $
Total
Date Current License on File C3 Yes 13 No a N/A
Comment:
IDATED (IN THIS SPACE) THIS IS YOUR PERMIT
WHEN PROPERLY VAL
Ag
Approved By:
• I