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''; � :,, -') <br />A�PLICATION FOR-=�: <br />'".E".'°'"° � CONSTRU�TION <br />Gltt OF <br />�verett PE RM I�T <br />BUILDING DEPARTMENT <br />259•8810 TO BE COMPLETED IN INK- PLEASE PqINT <br />L DEMOLITION ❑ COMBINATION �,BUILDING ai] R7Ef<'HANI :AL <br />OWNEN MAILROOFESS Gltt 21P <br />Tw c� To�Y. a�loo _ �� �-e- �`�-a-�l�'t.� q8 t o� <br />•11CHIT[ URDESIGNEF MRIIAD�RL55 GITY 21P <br />hM. u 1 u a.w�,.a.d� I,� i t�. � i-��-s I 2 z oo tilar}Q�,-�.�.p w a..r �.Lt.o w <br />L��Y � 21P <br />�� `�8�0 <br />cin zir <br />CITY 21P <br />❑ PLUMBIkG <br />FHONE <br />PMONE <br />�(- 7�oa <br />PNONE <br />�33•3Z33 <br />PHONE <br />everetl <br />e <br />❑ SIGN <br />IENSE • <br />oCf /B <br />ENSE � <br />ENSE • <br />❑ NEW ❑ ADDITION � AITEFATION ❑ REPAIR ❑ D[MOLITION ❑ WOODSTOVE/FqPL.INSERT ❑ BUILDING RELOCATION <br />�J UQION OF WOAKIGOST OF MAT I�LS PLUS LABORI <br />� /�1,�'.'�� <br />OiPRO�EflTVISNOWN <br />� �{OG <br />PLUMBING <br />TYPE OF FI%TURE OR ITEM <br />WATER CLOSET (TOILET) <br />BATFITUB <br />LAVATOHY (WASFI811SIN� <br />KITCHEN SINK Q OISP. <br />OISIiWASHER <br />UUNDHY TRAV <br />ClOTHES WASHER <br />UPINAL <br />ORINKING FOUNTAIN <br />FLOOR DRAIN ' <br />BACKFLOW PREVENTERS <br />ROOP OR 41N5 — RAINLFI <br />11L� N <br />OFBLOG. <br />�3f7 si <br />9UBTOTAL <br />PERMIT <br />TOTAL FEE <br />HE�HEET6�CK <br />LOTRpEA <br />OCGUPANGYGN01 <br />� � 2 <br />NO.OF STORIES <br />HECNED BY <br />/� <br />S <br />f <br />f <br />VnCANj S17E <br />OVES� GO <br />NO. OF DIVELLING UNIiS <br />�- <br />� <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP• <br />PLICATION AND KNOW TI1E SAMETO BETRUEANDCORRECT. ALL <br />PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE <br />OF WORK WILL BE COMPLETED WITH WHETHER SPECIfIED HERE- <br />IN OR NOT. THE GRANTING OF A PERMIT OOES NOT PRESUME TO <br />GIVE AUTHOfliTY TO VIOLATE�OR CANGEL THE PROVISIONS OF <br />ANY OTHEq STATE OR LOCAL LAW REGULATING CONSTRUCTION <br />OR THE PERFORMANCE OF CONSTRUCTION. . <br />SIGNATUPEOFCONIRACTORORAUTHORIZEDAGENT DATE <br />1w • <br />1TY UlI51NE55 LICENSE NO <br />MECHANICAL <br />NO. TYPE OF EOUIV <br />AIC — A/NNDLG UNITS — H.P. <br />PEFRIGERATION UNITS—F7.P. <br />BOILERS — B.T.U./H.P. <br />GAS FIRED A.C. UNITS — B.T.U. <br />FOFCED AIR SYSTEMS — B.T.0 <br />WALL HEATEHS — B.T.U. <br />UN�T HEATEFS — B.T.U. <br />EVAPORATIVE COOLERS <br />CLOTH65DRYERS <br />VENTIUITION FAN <br />RANGEHOOD <br />• WATEP HEA7ER <br />WOODSTOVE <br />METAL FIREPIACE 8 CHIMNEV <br />FIREPLACEINSERT <br />HEATPUMP <br />E%HAUSTFAN <br />PIAN CHECK NUMBER <br />M <br />M <br />0 <br />SUBTOTAL f <br />PCRMIT 7 <br />TOTALFEE L <br />IFEE AECEIPTNO. <br />7� 05 q>,ta <br />� FEES 1 <br />BUILDING S <br />PLUMBING <br />MECHANICAL <br />OTHER 55 US <br />STATE BUILOING SURCHARGE <br />STATEENERGYSURCHARGE <br />PUBLIC WORKS <br />TOTAL <br />s <br />PROPERTY OW NERS ARE RESPONSIBLE FOR DETERMININO ALL <br />PROPERN LINE LOCATIONSAND RELATED EASEMENT3. <br />