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PPLICATION LOFJ <br />CITYOOF �YLT�N <br />TAT FOlsen CONSTRUCTION 39)everett PERMIT <br />BUILDING DEPARTMENT 259•8745 TO BE COMPLETED IN INK- PLEASE PRINT <br />❑ DEMOLITION ❑ COMBINATION Yl BUILDING O MECHANICAL ❑ PLUMBING ❑ SIGN <br />MAR ADBOES9 CITY ZIP '11 n/JPGHOM/yN�E// <br />OWNEn W -ISWW G43-400 <br />CASCItbI: DEYE1 Df'MG-Wr GUP %25 3zkD. 5>= Seu EZIP A ! <br />ARCIIIIECI On OE910NER MAIL ADOOE9S CITY ,11( 21P PHONE <br />MEANIC IOACiop MAIL ADDRESS CIIV ZIP PHONE LICEIISE <br />PHONE LICENSE <br />PLUM.. NO LONIRACIOD <br />MAIL AODOE95 CITY ZIP • <br />ETAS! Oi WUOK <br />NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPLANSERT BUILDING RELOCATION <br />�25 coo <br />DiscniBE won r ,�, A A emu... IA m,)L, IGr2F-A.T /1!]1-hY7=c, �l <br />nT.,r In�t �wIrLn,l= �.E�� I�,, <br />a . _ .- . _- - - <br />useorBNRomo <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP- <br />PLICATION ANDKNOWTHESAMETOBETRUEANDCORRECT.ALL <br />OR AITAC11 i0Un COPIES) <br />PROVISIONS OF LAWS AN D ORD I NANCES GOVERNI NG TH IS TYPE <br />LEGAL OESCRIPIION OF POOPEBIY 1911:JWN 0ELOW <br />WORK WILL BE COMPLETED WITH WHETHER SPECIFIED HERE- <br />OF <br />IN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO <br />Lol_OlocK...—oF <br />GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OK <br />ANYOTHER STATEOR LOCAL LAW REGULATING CONSTRUCTION <br />iiTT-hG H,G� LIT��-,_ <br />OR THE PERFORMANCE OF CONSTRUCTION. <br />N II <br />SIGNATUR OFCONTnACTOR OR AUTHORIZED AGENT DATE <br />1�3/�1�11`�1��'lN6bw <br />X 1217� moo' <br />`T1T,( --11 <br />1� PLA7-A 11V� <br />`-^ •— "' <br />PnOJECT AOOnESS <br />APP CANT' It 0 SINE CENSENO. �,� .) 1� <br />c� A�CH'ITE-ar, ram'• <br />1 FP-I� PC—,(Nlt <br />7&e <br />MECHANICAL <br />PLUMBING <br />FEE <br />NO. TYPE OF EQUIPMENT FEE <br />ITp, TYPE OF FIXTURE <br />AIR COND. UNITS-II.P. E0. <br />_ WATER CLOSET (TOILET) <br />REFRIGERATION UNITS-N.P. EA <br />BNHTUB _ <br />-- <br />BOILERS-H.P. EA. -- <br />_ LAVATORY (WASI I BASIN) — <br />_ <br />GAS FIRED AC. UNITS -TONNAGE EA —_ <br />_ SHOWER — <br />-- <br />FORCED AIR SYSTEMS-B.T.U. MEA <br />KITCHEN SINK6DISP. <br />WALL HEATERS-B.T.U. M <br />_ DISIIWASIIER -- <br />UFIITHEATERS-B.T.U. M -- <br />LAUNDRYTRAY — — <br />EVAPORATIVE COOLERS -- <br />CLOTIIES WASIIER <br />GLORIES DRYERS -- <br />WATER IIEAtER <br />VENTILATION FAN <br />_ URINAL <br />-- <br />OOD -- <br />RANGE HOOD-DRINKING <br />DRINKING FOUNTAIN — <br />_ <br />AIR HANDLING UNIT- C.F.M. _— <br />_ FLOOR DRAIN <br />STOVE <br />_ VACUUM OREAKERS _ <br />__ <br />METAL FIREPLACE 8 CHIMNEY --- <br />_ ROOF DRAINS-RAINLEADERs <br />WOODSTOVE/FIREPLACE INSERT -- <br />SINK SERVICE -BAR. ETC. <br />SUBTOTAL s <br />SUB TOTAL <br />— <br />— <br />PERMIT s <br />PERMIT s <br />TOTAL FEE s <br />TOTALFEE $ <br />THIS PORTION TO BE COMPLETED BY BUILDING DEPT. PERSONNEL <br />NI SFIBACK <br />IIF. An SEInACK <br />SIDE SEIOACIt <br />ZONE <br />LOT AOFA <br />VACANT SITE <br />NA <br />ores �Tw <br />OF CON$L <br />OCCUPANCY GROUP <br />NO. OF OWELLIN� <br />: or BLOB. <br />ND OF STOOIE9 <br />MAK. OCC. LOAD <br />��a.Ia.zv <br />1 <br />5�c <br />APPI ICAI 1011 ACC BY PLAIISCNECKED BY APPn. ion ISSUANCE BY <br />EEE <br />FEE FEES VALUATION <br />IT <br />FEES VALUATION TEE <br />BUILDING <br />PLUMBING <br />MECIIANICAL <br />OTHER <br />PENALTY <br />TOTAL <br />s <br />