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fhe Evergieen <br />CITY OF <br />everett <br />BUILDING DEPARTMENT <br />259-8810 <br />e <br />�. y <br />APPLICAT'ION FOR CONST'RG TIO�N <br />PEFiMIT <br />TO BE COMPLETED IN INK — PLEASE PRINT <br />�sveose It..oa.fC� 5�3o SC.v f' �/ev�crr JL�aLL w�y z�veten' <br />AFCMITEGTOROESICNER MRILAD�PE55 CITY ° ZIP PHONE <br />everett <br />e <br />OENEFFLGONTRACTOF MRILFODFE55 LItY 21P PHONE IILENSE• <br />�q�cueir �ec�o.uicc(�tvG %d. /ScX /eYS IL704�SU�l'�= %�'�YS-u--�r'•t7O <br />IXASSOF WORK <br />� NEW ❑ ADOITION ❑ ALTERATION ❑ FEPAIR ❑ DEMO_ITION C WOODSTOVFJFRPL INSEFT ❑ BUILDING RELOCHTIGN <br />�iS �-,Ne'S <br />G-. <br />LOT dLUCN OF <br />I HEREBY CERTIFY THAT I t!AV[ READ AND E%AMINED THIS APPLICATION AND <br />KNOW THE SAME TO BL TRUE AND CORRECT. ALL PROVISIONS OF LAWS AND <br />ORDINANCES GOVERNING 7HI5 TVPE OF WORK WILI BE COMPLETED WITH <br />WHETH ER SPECIFIED H EREIN OR NOT.THE GRANTING OFA PFFMIT DOES NOT <br />PRESUh1E TO GIVE AUTIiORIN TO VIOLATE OR CANCEL THF. PROVISIONS OF <br />ANY OTfiER STATE OR LOCAL LAW REGULATING CONSTRUCTION O� THE PER� <br />FORMANCE OF CONSTAUCTION. THAT I AM AUTHuFIZED BYTHE OWPIER OF <br />THIS PROPERN TO PERFORM THE W�RK FOR WHICH APPLICATION IS MADE <br />AND I COMPLY `NITF' THE STATE CONTFlACTOFS V�W 10.27 RC\V AND <br />296200 WAC. <br />SIGNATOF[OFCONiRAQO'nOF.AUTHOii1ZE0FGENi ORfE <br />'i�jo S. w � ��.e d r1�e3a w a7( X�g-(r.X'�' �.m�i..N✓`? �Q �S' 9 <br />PROJECi AODRESS APPLICANTS CITY BUSINE55 LICENS[ NO. ANO BUSIN[55 Vi1ME <br />PLUMBING <br />� NO. TYPE OF FI%TURE OR <br />' WATERCLOSET(TOILEp <br />BATHTUB <br />' LAVATORV�WASH BASIN) <br />SHOWER <br />KITCHEN SINKB DISP. <br />� DISHWASHER <br />� LAUNDRYTRAY <br />. CLOTHES WASHER <br />URINAL <br />� DRINKING FOUNTAIN <br />� FLOOR DRAIN <br />BACKFLOW PREVENTERS <br />- ROOFDR?:�:5—fiAINLEAUERS <br />RLLOWr19LE/nCTUAL <br />FIRESPR�NKIEflSflEOUIREO ❑ <br />PERMIT <br />TOTALFEE <br />❑ NO <br />nv <br />C N <br />5 <br />❑ VES ❑ NO <br />FEE <br />MECHANICAL <br />NO. <br />A/C—.VHYDLG UNITS— Ii.P. <br />FORCED AIq S}STEMS— B.T.U. <br />UNITHfATERS—B.T.U. M <br />CLOTHES DRVERS <br />RANGEHOOD <br />WATER HEATER <br />WOOD STQVE <br />HEATPUMP <br />GAS PIPING <br />fEE <br />SUBTOTAL S <br />PERMIT S <br />TOTALfEE 5 <br />FEE PECEIPfNO. <br />VALUATION FEE <br />BUILDiNG <br />PLUMBING <br />MECHANICAL <br />OTHER <br />STATE BUILDING SURCHARGE <br />STATEENERGYSURCHARCaE <br />PUBLIC WORKS <br />TOTAL <br />a <br />