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The EvCTY OF ^,ONSTRUCTION <br />everett PERMIT PERMIT N0. 1OH4H <br />CITY HALL 259 8745 <br />EVERETT, WA 98201 ❑ COMBINATION kkBUILDING ❑ MECHANICAL ❑ PLUMBING <br />OWNER <br />MAIL ADDRESS <br />Madge M. Jacobsen <br />5122 Delaware <br />CITY <br />ZIP <br />PHONE <br />ARCHITECT 0, l`FSIGNER <br />Everett <br />252-8894 <br />Mgll Ap DRESS <br />CITY <br />ZIP <br />PHONE <br />GENERAL CONTRACTOR <br />MAIL ADDRESS <br />Same <br />CITY <br />JP <br />PHONE LICENSE <br />MECHANICAL CONTRACTOR <br />MAIL ADDRESS <br />CITY <br />ZIP <br />PNONE LICENSE I <br />PLUMBING CONTRACTOR <br />MAIL ADDRESS <br />CITY <br />ZIP <br />PHONE LICENSE I <br />❑NEW ❑ADDITION ❑ALTERATION EjfkPAIR El DEMOLITION ❑FENCE ❑SIGN ❑GARAGE <br />.UATION OF WORK _ <br />S2T000. <br />SCRIBE WORK <br />Re -roof change from comp. to RhAv.. <br />PROPOSED USE OF BUILDING <br />— <br />Single Family Residence <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP. <br />PLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT. <br />LEGAL DESCRIPTION OF PROPERTY(SHOW BELOW OR ATTACH FOUR COPIES) <br />LOT 90 BLOCK_OF Claremont Heights <br />ALL PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS <br />TYPE OF WORK WILL BE COMPLIED WITH WHETHER SPECIFIED <br />HEREIN OR NOT. THE GRANTING OF A PERMIT DOES NOT <br />PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PRO- <br />VISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING <br />CONSTRUCTION OR THE PERFORMANCE OF CONSTRUCTION. <br />SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT DATE <br />JOB ADDRESS <br />_5122 Delaware <br />X 8/6/82 <br />PLUMBING <br />MECHANICAL <br />_ <br />NO- TYPE OF FO.TLRE OR ITEM FEE <br />NO. <br />TYPE OF EQUIPMENT <br />FEE <br />WATER CLOSET (TOILET) <br />AIR COND. UNITS — H.P. EA <br />BATHTUR <br />REFRIGERATION UNITS — H.FEA <br />LAVATORY (WASH BASIN) _ <br />. <br />BOILERS — H.P. EA. <br />SHOWER <br />GAS FIRED A.C. UNITS—T014NAGE EA. <br />KITCHEN SINK 8 DISP. <br />FORCED AIR SYSTEMS — B.T.U. M EA. <br />DISHWASHER <br />WALL HEATERS—B.T.U. M <br />— <br />LAUNDRY TRAY <br />UNIT HEATERS—B.T.U. M <br />CLOTHES WASHER <br />EVAPORATIVE COOLERS <br />WATER HEATER <br />CLOTHES DRYERS <br />URINAL <br />VENTILATION FAN <br />DRINKING FOUNTAIN <br />RANGE HOOD <br />FLOOR DRAIN <br />AIR HANDLING UNIT <br />VACUUM BREAKERS <br />STOVE <br />ROOF DRAINS — RAINLEADERS <br />METAL FIREPLACE 8 CHIMNEY <br />SINK (SERVICE — BAR, ETC.) <br />SUB TOTAL <br />SUBTOTAL $ <br />PERMIT $ <br />PERMIT $ <br />TOTAL FEE <br />= <br />TOTAL <br />FEE $ <br />SIDE YARD SETBACK <br />STREET SETBACK <br />REAR YARD SETBACK <br />PLAN CHECK NUMBER <br />PLAN CHECK FEE <br />FEE RECEIPT NO. <br />USE ZONE <br />LOT AREA <br />VACANT SITF <br />DYES ONO <br />FEES <br />VALUATION <br />FEE <br />TYPE OF CONST. <br />OCCUPANCY GROUP <br />NO. OF DWELLING UNITS <br />BUILDING <br />$2 000. <br />32 <br />50 <br />SIZE OF BLDG. <br />NO. OF STORIES <br />MAX. DOC. LOAD <br />PLUMBING <br />FIRE ZONE <br />BASEMENT <br />FIRE SPRINKLERS <br />MECHANICAL <br />REQUIRED <br />DYES ONO <br />APPROVALS <br />BY <br />DATE <br />OTHER <br />1. ENVIRONMENTAL CHECK LIST <br />PENALTY <br />U.B.C. <br />2. BUILDING PLANS <br />SEC. 303 (a) <br />50 <br />3. FIRE HYDRANT <br />TOTAL <br />32 <br />4. FIRE PROTECTION SYSTEM <br />PERMIT VALIDATION <br />WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT <br />5. GRADING <br />5 9 f i $ 0 31. 5 0 --,c� <br />G. DRAINAGE <br />7. ENVIRONMENTAL IMPACT STATEMENT <br />CO. <br />YOUR 14E^^ <br />4 E I <br />8. HEALTH DISTRICT <br />APPLICATION ACC. BY <br />PLANS CHECKED BY <br />APPR, FOR ISSUANCE BY <br />THANK YOU ': <br />ADDRESS FILE 6' 8Y <br />