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%' PPLICATION 1`04 <br />CONSTRUCTION Be <br />everett PERMIT <br />TO BE COMPLETED IN BLACK INK- PLEASE PRINT <br />BUILDING DEPT. <br />259.8745 ❑ COMBINATION ❑ BUILDING ❑ MECHANICAL ❑ PLUMBING ❑ SIGN <br />gyKR MAIL ADDRESS CITY 21P PNONE <br />G7 4641-g.✓ opt) Bo /00642 Evf2fTi g�aoG Gs3 -ioyZ �}A <br />ARCHITECT OR DESIGNER MAIL ADDRESS CITY LP PHONE <br />AeReL/do,&,eezd,1 •L/a fs,6-,vnet 7orD!'dFP 2LA-%���� 112 97�a3 Edo-S/S3% <br />MECHANICAL CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE <br />PLUMBING CONTRACTOR MAIL ADDRESS 11,CITY ZIP PHONE LICENSE• <br />GU�B OF WORK - <br />FS7N ..�... I7 .nn,Ttnu n Al TFRATInN ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPL. INSERT ❑ BUILDING RELOCATION <br />USE OF SUIL ym <br />S,")%/lllx: - <br />/) EI HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP- <br />PLICATION AND KNOWTHE SAME TO BE TRUEAND CORRECT. ALL <br />LEGAL DESCRIPTION OFPIOPERTYIBHOWNBELOW ORATTACH FOUR COPIES PROVISIONS OF LAWS AND ORDINANCES GOVERNINGTHIS TYPE <br />OF WORK WILL BE COMPLETED WITH WHETHER SPECIFIED HERE- <br />LOT— BLOCK 0 IN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO <br />GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONSOF <br />ANY OTH ER STATE OR LOCAL LAW REGULATING CONSTRUCTION <br />OR THE PERFORMANCE OF CONSTRUCTION. <br />SIGNATUR F CONTRACTOR OR AUTHORIZED AGENT DATE <br />� ,./_ <br />PROJECT ADDRESS <br />APPL ANTS CITY BUSINESS LICENSE NO. / <br />PLUMBING <br />MECHANICAL - <br />NO. <br />TYPE OF FIXTURE <br />FEE <br />NO. <br />TYPE OF EQUIPMENT <br />FEE <br />WATER CLOSET TOILE <br />AIR COND. UNITS-H.P. EA <br />BATHTUB <br />RATION UNITS-H.P. EA <br />LAVATORY WASH BAST <br />--H.P. EASHOWER <br />SINK& -)ISP. <br />D AC. UNITS -TONNAGE EAKITCHEN <br />AIR SYSTEMS-B.T.U. M EA. <br />PBOPFRS-H.P. <br />ATERS-B.T,U. M <br />/ <br />LAUNDRYTHAY <br />CLOTHESWASIIER <br />WATER HEA ER <br />ATERS-B.T.U_ M <br />ATIVE COOLERS <br />S DRYERSURINAL <br />TION FAN <br />QQ- <br />MIL <br />DRINKING FOUNTAIN <br />FLOOR GRAIN <br />RANGE HOOD <br />AIR HANDLING UNIT- C.F.M. <br />/ <br />VACUUM BREAKERS <br />STOVE <br />ROOF DRAINS-RAI/ILEADERS <br />METAL FIREPLACE & CHIMNEY <br />WOODSTOVE/FIREPLACE INSERT <br />SINK SERVICE -BAR ETC. <br />0 <br />SUBTOTAL ! <br />SUB TOTAL <br />PERMIT { <br />PERMIT { <br />TOTAL FEE ! <br />TOTAL FEE ! <br />- <br />THIS PORTION TO BE COMPLETED BY BUILDING DEPT. PERSONNEL <br />REAR <br />USE ZONE <br />LOT AHEA <br />VACANT SITE <br />ONO <br />TYPE OF CONST. <br />V-" <br />OCCUPANCYGROUP <br />R <br />NO. OF DWELLING UNITS <br />1 <br />BUILDING <br />O SIZE OF BLD <br />317-1 $,m <br />NO. OF STORES'✓ <br />2 + $SA4 7I <br />1 <br />MAX OCC. LOAD <br />I <br />PLUMBING <br />� <br />FIRE SPRINKLERS REQUIRED ❑ YES G'RO <br />MECHANICAL <br />OTHER <br />PENALTY <br />APPLICATION ACC. BY <br />1 MA <br />PLANS'CIH,EC,K'ED BY <br />�,(1l 1 <br />APPH. FOR ISSUANCE BY <br />TOTAL <br />FEE <br />FEES I VALUATION I FEE <br />