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( <br />APPLICATIbN FOR CONSTRUCI-.bN PERMIT <br />flre Evelgreen <br />cilv oF <br />everett <br />BUILDING DEPARTMENT <br />259-8810 Tn BE <br />❑ DEMOLITION ❑ COMBINATION <br />OWNEH MRILAOORE55 <br />86ARIaE� i�c. R5 2z �, <br />TENRNT�� � � MAIL AUURE55 <br />CLA55 OF WOPI( <br />❑ NEW DDITI( <br />TENANT IAIPROVEMENT OF I <br />CONTF�CT PRICE OF WOR <br />OESCRIBE WOPK AND SOU � <br />�,oADI Uoc <br />PROPOSED USE OF BUILDINQ <br />MAIL ADDRESS <br />ETED IN INK—PLEASE PRINT <br />11LDING Cl MECHANICAL <br />CI'V 21P P1� <br />�E V�tiw DR�ve ���,tJ <br />CITV ZIP Pf <br />CITY Zlv <br />c��� <br />GTY 21P <br />CITY 21P <br />I 1 PLUMBING <br />'L�R .-S� <br />rnunt <br />PMONE LICENSE� <br />> SS-'�GG% �o-f�Z. <br />PHONE LICENSE • <br />PHONE LICENSE I <br />everett <br />e <br />❑ SIGN <br />ri eiTcoennu I 1 FFPAIR f-1 nFAAnIIiInN f I WOO�S70VE/FRPLINSERT ❑ BUILDINGRELOCATION <br />INVOIVED <br />LEO�AL/D�ESCRIPTION OF PROPEf7TV �S��OWi19ELOW OBGATTFC/N <br />L0T7r� I�BLOCK �� OF G� �/' <br />' N0. TYPE OF FI%Ti <br />' WATER CLOSET (TOIL <br />BATHTUB <br />� LAVATORY(WASH BA: <br />. SHOWER <br />; KITCHEN SINK 8 DISP <br />� DISHWASHER <br />. � ��u�novToev <br />0 <br />URINAL <br />DRINKING FOl <br />FLOOR DRAIN <br />BACKFLOW PF <br />ROOF DRAINS <br />FRONTSETBACK <br />USE ZONE <br />�-� <br />1YPE OF CON57 ALLOWABIE <br />SIZE OF BLDO. <br />OCCUPANCYLOAU <br />REASON FOR SPRMKLERS <br />APPUCATION ACC. BV <br />FEE <br />GONIACT PEPSON ANO PlIONE NO. <br />I HEAEBY CERTIFY THAT I HAVE READ AND EXAMINED THIS <br />APPLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL <br />PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE OF <br />WORK WILL BE COMPLETED WITH WHETHER SPECIFIED HEREIN OR <br />NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE <br />AUTHORITY TO VIOLATE OR CANCEI THE PROVISIONS OF ANY <br />OTHER STATE OR LOCAL LAW REG' ILATING CONSTRUCTION OR THE <br />PERFORMANCE OF CONSTRUCTION. THAT I AM AUTHORIZED BY THE <br />OWNER OF THIS PROPERTY TO PERFORM THE WORK FOR WHICH <br />APPLICATION IS MADE AND I COMPLY WITH THE STATE <br />CONTRACTORS LAW 18.27 RCW AND 296.200 WAC. <br />SIGNRTUtiEOFCONTliACTO(IONAUTNON12EORGENT DATE <br />X ��1� ��1� �, <br />NO. AND BUSINESS NRME <br />E�UIPMENT <br />FORCED AIR SYSTEMS—B.T.U. <br />UNIT H=ATERS—B.T.U. M <br />CLOTHES DRYERS <br />VENTILAiION FAN <br />RANGEHOOD <br />WATER HEATER <br />WOOD STOVE <br />METAL FIREPLACE 8 CHIMNEY <br />FIREPLACE INSERT <br />FAN <br />SUB TOTAL $ ; SUB TOTAL <br />PERMIT $ �— PERMIT <br />TOTAL FEE $ ' TOTAL fEE <br />REAR SETBACK SI�E SETBACK P E UMOE FEE <br />_ � ,�; �,� Cn�/ � `' <br />LOT AAEA VRCPNT SI7E FEES VALUATION <br />I I vES -H'NO euuoiNc � <br />itPEOFCON51.1t1UAL octU�extr No IXOaTIUMGUMns <br />GP0°' PLUMBING <br />� <br />NO.OFSTORIES Br15EMENT MECHANICAL <br />l l YES I-I NO <br />FIRESPRNNLERSliEO� NEIC+HTLIMIipTION OTHER <br />❑ YES Ll NO � <br />STATE BWLOING SURCH�RGE <br />STATEENERGVSURCHARGE <br />V`LANSAPPROVCDBV CITY OF EVERETT PUBLIC WORKS <br />LOCAL SnIES <br />I TAX CO�EIS 3105 T�TAL <br />5 <br />S <br />; <br />i <br />i <br />