Forms • McCook, NE • CivicEngage

Job Address:*

Property Owner Information

Name:*

Address:

City/State/Zip:*

Phone:*

Email address:

Owner's electronic signature:

Date:

Contractor Information

Business Name:

Address:

City/State/Zip:

Phone:

Email address:

Contractor Information:

Date:

Is Contractor licensed?

Yes

No

Type of Work

	No construction
	Add./alt./replacement

	Demolition
	Other

If other, please explain:

Category of Construction

	1 & 2 Family dwelling
	Multifamily
	Accessory building

	Commercial/Industrial
	Other

If other, please explain:

Description of Work
(example: upstairs bath fan/dryer exhaust)

Total project cost:

FEE SCHEDULE-USE CHECKLIST

$25 Min. plus $3.00 per item over 6 items

Description

QTY.

Air conditioner

Furnace

Heat Pump

Air handling unit

Hydronic hot water system

Boiler

Unit heaters

Vent relocation

Ventilation fan

Decorative gas fireplace

Flue vent for water heater or gas fireplace

Wood/pellet stove

Gas or wood fireplace/insert

Chimney/liner/flue/vent

Clothes dryer vent

Other

If other, please explain:

Gas fuel piping

Furnace, etc.

Gas heat pump

Wall/suspended/unit heater

Water heater/boiler

Fireplace

Range

Barbecue

Clothes dryer

Other

If other, please explain:

TOTAL

* indicates required fields.

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