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LA <br />-- <br />CC"STRUCTION <br />PERMIT APPLICATION <br />COMBINATION • 13UILUING F' MECHANICAL PLUMBING <br />OWNER MAIL ADDRESS ZIP PHUNt <br />y� <br />l.. I lctivr <br />ARCHITECT OR DESIGNER M <br />PHONE LICENS! NU�L <br />GENERAL CONTRACTOR ADDRESS <br />PHONE LICENSE NO. <br />MAIL <br />MECHANICAL CONTRACTOR MAILAODRi.FS <br />PHONEY LICENSE NO. <br />PLUMBING CONTRACTOR MAIL ADDRESS <br />PHONE LICENSE NO. ' <br />PERMIT <br />CLASS OF WORK <br />-��- <br />❑COMBINATION <br />BUILDING []PLUMBING ❑MECHANICAL <br />❑YEW <br />[]ADDITION ALTLf1A T14N- ❑IIU'nIR <br />VALUATION OF WORK <br />❑DEMOLISH <br />FE❑❑S <br />❑NCE SIGN WIMMINO P(101, <br />I /~000 I <br />DESCRIDE W4 <br />- r <br />AW /,/EF✓ R�•T/'r/srf lfc,04 L <br />E71/ <br />PROPOSED USE <br />OTHER PER TS OR APPROVAL <br />_ <br />j3 REZONE $j SPECIAL USE <br />LEGAL UESC RIPTION OF PROPERTY (SHOW BELOW OR ATTACH <br />FOUR COPIES) <br />}• <br />$VARIANCE 11 SN.ORLINE <br />LOT BLOCK— OF <br />SEPA CHECK LIST REQUIRED <br />E LFcwRL <br />/ C t✓,r "') <br />= YES <br />3ZI NO <br />iLr _ w Ckj_1Zr71_ f,07 <br />L <br />JOB ADDRESS <br />iMECHANICAL <br />,T•,3O <br />PLUMBING <br />TYPE OF ENERGY <br />El AS ❑FLF. C. <br />NO. TYPE OF EOUIPME_NT _ _ _ FEE <br />_COND. <br />_ <br />AI RUNITS-H.P. EA. Is 1 <br />- REFRIGERATION UNI ES H.P. LA. I-�— <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />RATH TIIUS <br />S _1 <br />-- <br />BOILERS H.P. EA. ---1-�_--�-�- <br />FORCED AIR SYSTEW,'.-B.T.U. MEA <br />1 <br />CLOTHES WASHER <br />I <br />T-- <br />DISH V,,\SHEHS <br />I <br />-. ___. _. - <br />_ <br />H.T.U.ING <br />SPACE &WALALL HEATERS �• <br />-H. <br />---L-- <br />I <br />FOUNTAINS <br />T <br />I _ <br />Fl OH DRAINS <br />FLOOR <br />1 <br />KITCHEN SINKS & OISP. <br />1 <br />UNIT HEATERS B.T.U. <br />i <br />--r— <br />HAH SINKS <br />1 <br />EVAPORATIVE COOLERS <br />ROOF DRAINS RAIN LEADERS <br />I <br />CLOTHES DRYERS <br />_ I <br />_T— <br />SHOWER BATHS <br />VENTILATION FAN �- <br />SERVICE SINKS <br />RANGE HOOD I <br />SUMPS - SEWAGE PUMP <br />AIR HANDLING UNIT C.F,M. <br />URINALS <br />WATER CLOSETS 1 <br />_ -.... .... �... . _ _.. .. �.. 1 <br />- - '-' <br />HE AT[115 - ELF.CTIiIC i <br />HEATERWATtB <br />..._ _.WATER HEATER <br />WA511 BASINS - 1 <br />FAC. BUILT FIREPLACE_& CHIMNEY 1 <br />LAUNDRY TRAYS • <br />_ _ _ _ <br />GAS. SYSTEM NO OP OUTLLIS <br />- __ ..... . _ _..--._.. <br />sun mrnL S 1 <br />PERMIT <br />TOTAL FEE S 1 <br />- SUR TOTAL <br />PERMIT I <br />T111S PF ii MIT UECOM ES NUI L. AND VOID It WORK OR CONSTRUC <br />_ <br />TOTAL FEE <br />TION AUTIIOnIZEO IS NOT COMMENCED WITHIN 120 DAV5, OR IF <br />CONSTRUCTION On WORK Bi SUSPI: NDED Oil ABANDONE13 FOR A <br />WATER SERVICE Si7E SUPPLY SIZE <br />PERIOD OF 120 DAYS AT ANY TIME AFTE11 WORK IUCOMIAFFICED. <br />_BLDG. <br />a o L dAC HLARVAHDSLTUACK' <br />I IILRLRY CERTIFY 'FIAT 1 HAVE READ AND E%AMINLD TIIIS AP <br />PLICATION AND KNOW TIIL SAME TO BE TRUE AND COIIRI:CT. ALL <br />PROVISIONS OF LAWS AND ORDINANCES GOVERNING TIIIS TYPE <br />- _C07WRLA'_'WE—ANf'fiTTt7 <br />OF WORK WILL HE COMPLIED WITH WHETHEFI BPECIFILO HEREIN <br />^- <br />U:1! ZONE <br />OR NOT, TIIE GRANTING OF A PERMIT DOES NOT PRESUME TO <br />GIVE AUTHORITY TO VIOLATE On CANCEL THE PROVISIONS OF <br />OYES ❑NO <br />AN, OTHER STATE On LOCAL LAW REGULATING CONSTRUCTION <br />TYPE OI' CONST. OCCUPANCY GROUP NO. OF DWELLING <br />OR THE PERFO'd ONST RUCTIO N. <br />UNITS <br />SIZE OF BLDG. NO. OF STORIES MA%.OTC. LOAD <br />7 <br />SI URE OFCONTRACTOFIORAUTI/. AGENT AT <br />111/i ZO1Jt-- 11/1.1F A1�N1 11111 .51'i11 N1. 1.L 115 <br />RLOUIFIEII <br />❑YLS []NOJO <br />LAN C/ILCK NVh1U EH PLAN CHECK FEL <br />— <br />F6C &'!T RECEIPT NO. <br />✓ <br />'SPECIAL CONDITIONS: <br />- _ <br />/ //���� �d C/(J,S� <br />7 <br />_ FEES VALUATION FEE <br />,..__ <br />—'----'-'---_ <br />BUILDING I 1 <br />I <br />' <br />SEPA REVIEW COMPLETE: ❑YES ❑ NO <br />PL UMBI NO <br />_ <br />contact plannlnq dept. <br />I <br />MLCHANICAL I <br />OTHER I <br />