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tN Ev�rprNn <br />cin oF <br />everett <br />�1 ��. <br />��'PLICATION FOR� <br />CONSTRUCTIqN <br />PERMIT <br />everelt <br />�v <br />BUILDING DEPARTMENT TO BE COMPLETED IN INK- PLEASE PRINT <br />259•8810 - <br />❑ DEMOLITION ❑ COMBINATION ❑ BUILDING ❑ MECHANICAL PLUMBING ❑ SIGN <br />OWNEP MAIIA�DRES$ C�LY ZIP P��ONE <br />F�ro Tovc� C�G� glz5 Everqvee� 1�1N Ever�.� `i82o3 ��17-5500 `, <br />._.,...........,..ee�nuca MRILADORE55 CITY 21P PMONE <br />GENEP�LGONiPPCiOR MRIL�DOBE55 W�Y 21P PHONE LILENSE• <br />MECMGN�C4LGONTRACiOq MAIL�O�RE55 CIfY ZIP PMONE 4CENSE• <br />PWMBINOCONiRALTOR M��LAODNE55 CRY LiP PNONE LICENSE• <br />GL�SS OF WOHN <br />❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPL.INSERT BUILDING REI.00ATION <br />VALUrT10NOFW011N�C09TOFA1RIERIFLSPW5LP90Pl ' � <br />�oT_ <br />': PLUMBING " <br />;y� ryp, TYPE OF FU(TUHE OR <br />WATER CLOSET (TOIIET) <br />��' BATMTUB <br />�� � <br />� �AVAT(�FV (WASH BASIN� <br />SHOWER <br />�� KITCHENSINK801SP. <br />'� OISFiWASHER <br />�� LAUN�PVTRAY <br />1 — <br />';� CLOTHESWASHER <br />! � URINAL <br />.;I <br />'��i DRINNING FOUNTAIN <br />�'� FLOOR DPAIN <br />�� ' BACNFLOW PREVENTERS <br />�� ROOFDRAINS—FlA�NLEAOEFS <br />�A SINH �SEPVICE —9AR. ETC.� <br />OF <br />ON PCL BY <br />� <br />SUBTOTAL S ' <br />PERMI7 f <br />TOTALFEE S <br />R SETBACR S��E SETBAGtt <br />ARE� Vr1CRNT5ITL <br />❑YES ONO <br />:UPRNLYGR011P ND.OFpWELLIN <br />OF STOPIE9 MA% OCQ LOAD <br />) ❑ YES ❑ NO <br />�NS CNECKEO BY APPF. FOH ISSU� <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP• <br />PLICATION AND KNOW THE SAME TO BETRUEAND CORRECT. ALL <br />PROVISIONS OF LAWSAND ORDINANCESGOVEFNINGTHISTYPE <br />OF WORK WILL BE COMPLETED W�TH 1NHETHEfl SPECIFIED HEflE• <br />IN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO <br />GIVE AUTHORITY TO VIOLATE OR CANC�L THE PROV�SIONS OF <br />ANY OTHER STATE OR LOCAL Lp4! REGULATING CONSTRUCTION <br />OR THE PERFORMANCE OF CONSTRUCTION. <br />SIGNATURE OF CONiFACTOR OR AUTNORIZED AGENT OATE <br />t <br />X `�\� ��, �.�� n i_ _�S—oQ <br />MECHANICAL <br />TYPE OF EOUIPME <br />A/C — A/HN�LG UNITS — N.P. <br />REPRIGEFATION UNITS — M.P. EA. <br />BOILERS — B.T.U./H.P. <br />GAS FIRED A.C. UNITS — B.T.U. <br />FOflCEO AtP SVSTEMS — B.T.U. <br />WALL HEATEFS — B.T.U. <br />UNIT HEATERS — B.T.U. <br />CVAPORATIVE COOLERS <br />CLOTHESORYERS _ <br />VENTILATION FAN <br />RANGEHOOO _�_ <br />WATEII HFATER <br />W OOD STOVE <br />METAL FIREPLAf,E d CHIMNEV <br />FIPEPLACE WS�RT <br />HEAT PUMP <br />GAS I'IPINO <br />E%HAUSTFAN <br />PLAN CHECK NUMBER <br />FEES <br />auaoiNc <br />PLUMBING <br />MECMANICAL <br />SUBTOTAL <br />PENMIT <br />TOTAL FEE <br />I FEE <br />$ <br />M EA. <br />M <br />M <br />RECEIPT NO. <br />OTHER <br />STATE BUILOING SURCHAHGE <br />STATEENERGYSUFCHARGE <br />PUBLIC WORKS <br />TOTAL <br />PROPERTY OWNERS ARE RESPONSIBLE FOR CETEfiMINING ALL <br />PROPERTV LINE LOCATIONS AND RELATED EASEMENTS. <br />.� . . . • � n. . . . ':f :. i� . •.... .. ... . <br />� <br />