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`.ti <br /> ;�:�r� � � �:=�PP �LICATION Fa::� ' <br /> � F'""' � CONSTIRUCTIOI� `°°"" <br /> ,'i ,verett PERMIT e <br /> ? ,UILDING DEPARTMENT <br /> 259-87a5 TO BE COMPLETED IN INK• PLEASE PRIMT <br /> ❑ D[MOLITION ❑ COMBINATION ❑ BUILDING ❑ MECHANICAL ❑ PLUMBING ❑ SIGN <br /> OWNEH . MMLAO�RESS LITY ZiP pNONE <br /> �o.1A«1=• � � ll � rn�. � 1'3c�zn z�'c( i��.r ' .� C�Z2arT � G�2oY 337-y�'j/� <br /> •pGNITEGTOROESIGNER MAILADOHE53 GITY 21P PMONE <br /> GENEIULCONTfl�CIDH EUiI��ORESS G�IY ZIP PHONE LILENSE• <br /> b w.0 Fne <br /> MELMI.NIC�L GONTR�GTOq M�IL AODRE55 CIIY 2iP PNONE LICENSE• <br /> PLOMBINOGONiR�GiOB M�IL�ODRF.53 CiiY 21P PIIONE LICEN9E• <br /> CUSS OF WORK <br /> ❑ NEW ❑ ADDITION ❑ ALTERATION � REPAIR ❑ OEMOLITION ❑ WOODSTOVE/FRPLINSERi ❑ E�1fLDINd RELOCATION <br /> V NOFWO.K�WSiOfM�TEHI�l5PW5L�B0111 <br /> Ci o n c� <br /> DE IBEWORY. ��n�� UNSO�.t�/YSR• � 'V � <br /> orN Po?c'.{r l7ap/�cJ AlG i?o�7�: o�C i�ilMi►Go�� <br /> a C e . �1- ' s 'v —Ao.��a� G�'•C.�../�. / l'U/1'u.e.�"' <br /> use or evaoiNa � - --��,�r� <br /> ��5,����� I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THTS AP- <br /> PLICATION AND KNO W THE SAME TO BE TR UE AND CORRECT.ALL <br /> LEO�lOESGPIPT10HOiPROVEPTYISMOWNBEIOWOR�Tt�GNFOURCOPIESI pqpyI510NSOFLAWSANDORDINANCESGJVERNINGTHISTYPE <br /> OF WORK WILL BE COMPLL"TED WITH WHETHEfl SPECIFIED HERE- <br /> �or_e�oc�_or • INORNOT.THEGRANTINGOFAPERMITDOESNOTPRESUMETO <br /> GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OK <br /> _ ANY OTH tR STATE OR LOCAL LAW REGULATING CONSTRUCTION <br /> OR THE PERFORMANCE OF CONSTRUCTION. � <br /> SIGNqTURE OF CONTR�CTOR OR AUTHOR12E0 AGENT DATE <br /> X�Q.,,zy�—�svv�2�--�... C���!—'�? <br /> PPOJECT�DORESS �PPLIC�NTS GiY BUSINE55 UCENSE NO. <br /> 3�/� �/JD�cl�i� L�v6i'<.a!l L.I�L <br /> VLUMSINO MECHANICAL <br /> NO. TYPE OF FIXTURE FEE NO. iYPE OF EOUIPMENT FEE <br /> WATEP CLOSET TQILE A�P COND.UNITS—H.P.EA. <br /> B�THTUB qEFpIGERRTION UNITS—H.P.EA <br /> LAVATORY WASH BASIN BOILERS—H.P.EA. <br /> SMOWER G�5 FIRED AC.UNITS—TONNAGE EA <br /> KITCHEN SINK 8 OISP. FORCED AIR SVSiEMS—B.T.U. M EA. <br /> DISHWASMER WALI HEATERS—B.T.I/. M <br /> LAUNDRYTR�V UNITHE�TERS-8.'f.U. M <br /> CIOTME3 WASHEF EVAPORATIVE COOLERS <br /> WATFn HEATER CIOiFIES OPVERS _� <br /> URI�'A�_ VENTILATION FAN <br /> DRINA'INO FOUNTAIN qANGE HOO� <br /> FLOOR ORAIN pIR MANOLING UHIT— C.F.M. <br /> VACUUM RREAKERS STOVE <br /> ROOF DRA.f15—NAINLFADERS MEIAL FIREPU E d CNIMNEY <br /> SINK SERVICE—B�R ETC, WOODSiOVE/FlREPLALEINSERT <br /> SUBTOTAL SUB TOTAL i <br /> PERMIT f PERM17 t <br /> _ TOTALFEE { TOTALFEE f <br /> TH15 PORTION TO BE COMPLETED BY BUILDING DEPT. PERSONNEL <br /> FRONTSE!BACIt RE�RSEfB�CK SiDESGTB�CK PL�NCHECNNl1MbER VUNCNECRFEE <br /> fEE RECEIPT80. <br /> USEZONE LOi�REA yhC�NT5ITE <br /> ❑YES ONO FEE! V�LUATION FEF <br /> TYPEOFCpNST. OCCUP�NCYGROUP NO.OFOWEL�IN6UNIi5 <br /> BUILDING S <br /> S12E OF BlDO. NO.OF SiOPIF.S M�a OCC.t0�0 <br /> � PLUMBIN6 <br /> �L <br /> MECHANICAL <br /> FIRE SPRINKLERS REOUIRED ❑VES ❑ NO <br /> OTNER <br /> PENALTY <br /> •PPLIC�110N�CC.9Y PUNSCNECNEUBY �PPFFORISSU�NCEBY <br /> TOTAL <br />