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Fr <br />CC''STRUCTION <br />PERMIT APPLICATION <br />COMBINATION • BUILDING • MECHANICAL • PLUMBING <br />OWNER MAIL/ADDRESS <br />_ ZIP PHUUNE <br />LC AI <br />� LIT �I <br />z <br />ARCHIT EC7 OR DE51(iNER—' I <br />/ <br />MAIL <br />ADDR S <br />)HONE LICENSE NU <br />GENERAL CONTRACTOR MAIL <br />ADDRESS <br />PHONE LICENSE NO. <br />MECHANICAL CONTRACTOR MAIL ADDRESS <br />PHONE LICENSE NO. <br />PLVMUINGCONTRACIOR MAILADDRESS <br />l-� <br />PHONE LICENSE NO. <br />PERMIT <br />CLASS OF WOnK <br />❑COMBINATION <br />BUILDING ❑ PLUMBING ❑ MLCRANICAL <br />❑NEW <br />❑ADOITIUN ALTE TIA TION ❑1/E I'A111 <br />VALVA710N OF WORK <br />_ <br />OO <br />❑OEMOLISH <br />❑FENCE ❑SIGN ❑SWIMMINU POOL. <br />S <br />DESCRIBE WORK <br />A/E RXT/'rlFrJ cI1L <br />t <br />.�rt, A-/GkL-— <br />, <br />PROPOSED USE _ <br />OTHER PERMiTS OR APPROVAI <br />Cr <br />.43 REZONE ] SPECIAL USE <br />LEGAL OtSCnIPT ION OF PROPERTY <br />IS HOW BELOW <br />FOUR COPIES) <br />OR ATTACH <br />#VARIANCE Lj SNORLINE <br />LOT BLOCK —OF <br />5 EPA CHECK LIST REQUIRED <br />zz-ywL <br />/ NC , <br />oi✓ <br />= YES <br />IZI N O <br />iLt _ w L-yFizr /T dL1�C Of�r <br />JOB ADDRESS <br />O <br />AMECHANICAL <br />e 44 <br />PLUMBING <br />TYPE <br />OF ENERGY <br />On AS _ [It LE C. <br />__ TYPE OF EQUIPMENT FEE <br />NO. <br />AIR_COND. UNITS-H.P. EA. 1 <br />RkF RIGERATION U_NIfS ILV. En. —I� <br />—_1 <br />nO1LEn5 H.P. EA. ---------- I <br />fORCEO AIR SYSTEMS U.T.U. ME A. --1� <br />---- --STEM ---- --i-- <br />_ <br />SPACE b WALL HEATERS- R.TT— <br />_ .U. I <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />_- <br />HAIR 1IIB.l <br />S <br />CLOTHES WASHER <br />DISH WASHERS <br />I <br />DRINKING FOUNTAINS <br />FLOOR DRAINS <br />1 <br />KITCHEN SINKS Pr DISP <br />—� <br />UNI71;EATFRi B.T.U. <br />BAH SINKS <br />I <br />OHATIVE COOLERS--�— <br />ROOF DRAINS RAIN LEAOEHS <br />HES DRYERS <br />1 <br />SHOWER BATHS <br />ILATION FAN <br />AN <br />SERVICE SINKS <br />E 1i00D I <br />SUMPS - SEWAGE PUMP <br />ANDLING UNIT C.F.M. <br />URINALSWAIER <br />JAIH <br />CLOSETSWATLgIIEATEIIS- <br />ELECTRIC <br />I <br />ER IIEATERWASH <br />BASINS - <br />1 <br />BUILTFIREPLACE b CHIMNEYLAUNDRY <br />TRAYS <br />SYSTEM NO OP OUTI.L.IS <br />9U0 TO FAL S <br />PERMIT <br />-- <br />SUB TOTC.L <br />I <br />_SEES----- TOTALFEE S — <br />_ <br />PERMIT s <br />THIS PEti1Al UECOMES NUL I. ANO VOID I WOI1K LIR CONST RUC <br />1z <br />TION AUTIIORIZED IS NOT COMMENCED WITHIN 170 DAYS. OR IF <br />TOTAL FEE <br />CONSTRUCTION On WORK It: susPCNDEO Oil ABANDONED FOR A <br />WATER SERVICE S17E BLDG. SUPPLY <br />SIZE <br />PERIOD OI' 170 DAYS AT ANY TIME AFTER WOFIK IS C(iMLIF.NCEU. <br />..CK I'S'l-TIrFT-1E Ia1LK HEAR YARD SE TUACK <br />1 IILREIIY CERTIFY THAT I HAVL HEAD AND LKAMINLO 1`1115 AP <br />PLICATION AND KNOW THE SAME 1'0 111, TRUE AND CORRI:f-T. ALL <br />PROVISIONS OF LAVIS AND OHDINAN]F' GUVEnNING 114I1 TYPE <br />OF WORK WILL BE COI:: PLIED WITH WHETHER SPECIFILD HEREIN <br />UBL'%GNL lUl AHLA VACANT <br />GITL <br />On NOT. TIIE Gn AN71NG OF A PERMIT OBE.^. NOT PRESUME TO <br />171VE5 ONO <br />GIVE AUTHORITY TO VIOLATE OR CANCtL THE PROVISIONS OF <br />TYPE OF CONST. OCCUPANCY URDU,- NU.OF DWELLING <br />ANY OTHER STATE On LOCAL LAZY )REGULATING CONSTRUCTION <br />OR THE PERFOR CONSTRUCTION. <br />UNITS <br />$IZCOF ULOG. NO. OF STORIES MAX. OCC. LOAD <br />/ <br />1'1HO Yf1NE —� IIA:'h AAI NI IlRl SPRINKLERS <br />SI' URC OF CONTRACTOR RACTOH OR AUTII. AG EE NT DATE <br />REOUIRLD <br />❑YES ❑NO <br />PLAN CHECK NUMOER PLAN CIILCK FLL <br />'7 TLC RECEIPT NO. <br />SPECIAL CONDITIONS' <br />qq <br />FEES VALUATION FEE <br />-'— <br />BUILDIh: S 1 <br />-r--- — -- -- - — — r - <br />SEPA REVIEW COMPLETE: OYES <br />❑ NO <br />wMmNr. <br />contact plannlnq dept. <br />_ <br />MLCIIANICAL <br />OTHER I <br />AMOCMIUBALLIRLUYY MUR9 LIIfCFIY YT AMRUYIO/UKI AWI 91 <br />PENALTY SEC. 3001d 1 <br />1 <br />C: <br />TOTAL I I <br />I <br />