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I <br />the Evergreen <br />CITY OF <br />everett <br />BUILDING DEPARTMENT <br />259-881 D <br />APPLICATION FOh <br />CONSTRUCTION <br />PERMIT <br />TO BE COMPLETED IN INK - PLEASE PRINT <br />❑ DEMOLITION ❑ COMBINATION ❑ BUILDING ❑ MECHANICAL ❑ PLUMBING <br />DWNER MAIL ADDRESS CITY ZIP PHONE <br />❑ SIGN <br />ITECT On V}.RIGNF. R MAIL ADDRESS w ZIP PHONE <br />PAL CONTRA.V OR MAIL ADDRESS CITY ZIP PHONE LICENSET—' <br />MECHANICAL CONTRACTOR wIAIL CITY ZIP PHONE LICLNSEA <br />PLUMBING CONTRACTOR MAIL ADDRESS CITY ZIP PIT NE LICENSE <br />CLASS OF WORK ,_1 <br />❑ NEW ❑ ADDITION S ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPL.INSERT ❑ BUILDING RELOCATION <br />VAL IONOFWORxICOST OF MAI E FLAILS PLUS LABOR, <br />DESCRIBE <br />/fNu A/..�T�/ GrA ri. i..-d✓ L/.a� D .:7a.i- G1i .\�_-. _-T. <br />E OF B LDING <br />G�i <br />2�� <br />�— <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP. <br />PL (CATION AND KNOW THE SAME TO BE 'RUE AND CORRECT 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 DOES NOT PRESUME TO <br />GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF <br />ANY OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION <br />OR THE PERF ANCE OF CONSTRUCTION. <br />SIGNATURE O ' TRACTOR OR A ORIZED AGENT DATE <br />LEGAL DESCRIPTOR OF PROPERTY (SHOWN BELOW OR AT TACH FOLIO CON[ 5) <br />LOT_BLOCK —_OF <br />/� AIL <br />PR JJ 77A DRESS <br />V A[ �� q O <br />APPLIC TSCITY BUSIN SE NO <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />NO. <br />TYPE OF'SOUIPMENT <br />FEE <br />WATER CLOSET (TOILET) <br />A/C — A/IiNDLG UNITS — H.P. <br />BATHTUB <br />REFRIGERATION UNITS — H P EA. <br />LAVATORY (WASH BASHI <br />BOILERS — 9.T.0 /H R <br />SHOWER <br />GAS FIRED A.C. UNITS — B.T.U. <br />KITCHEN SINK 6 DISP. <br />FORCED AIR SYSTEMS — B.T U. M EA. <br />DISHWASHER <br />WALL HEATERS—B.T.U. M <br />LAUNDRYTRAY <br />UNIT HEATERS—B.T.U. M <br />CLOTHES WASHER <br />EVAPORATIVE COOLERS <br />URINAL <br />CLOTHES DRYERS <br />DRINKING FOUNTAIN <br />VENTILATION FAN <br />FLOOR DRAIN <br />RANGE HOOD <br />BACKFLOW PREVENTERS <br />WATER HEATER <br />ROOF DRAINS — RAINLEADERS <br />WOOD STOVE <br />SINK (SERVICE — BAR, ETC) <br />METAL FIREPLACE 8 CHIMNEY <br />FIREPLACE INSERT <br />HEAT PUMP <br />GAS PIPING <br />EXHAUSTFAN <br />SUBTOTAL <br />S <br />SUBTOTAL <br />PERMIT <br />S <br />PERMIT <br />TOTAL FEE <br />S <br />TOTALFEE <br />PLAN CHECK NUMBER <br />9-� ao/oa <br />FEE C <br />8 <br />RECEIPT NO. <br />4768 <br />FRONT SE iBACx <br />za <br />REAR SEiDACK <br />� <br />SIDE SETBACK <br />c <br />USE ZONE <br />LOTAREA <br />VACAN sI <br />OYES O <br />FEES <br />VALUATION <br />FEE <br />BUILDING <br />S <br />TYPE OF SLWT <br />_>r� /V <br />OCCUPANCY GROUPDWE <br />� <br />{(' G <br />NO O I LING UNITS <br />•� <br />PLUMBING <br />SIZE OF BLDG <br />NO OF STORIES <br />�f <br />H <br />MAX OCC LOAD <br />MECHA' CAL <br />— <br />FIRE SPRINKLERS REQUIRED D YES NO <br />OTHER <br />STATE BUILDING SURCHARGE <br />sn <br />STATE ENERGY SURCHARGE <br />APPLICATION ACC BY <br />PLANS CHECKED BY <br />APPR FOR ISSUANCE BY <br />PUBLIC WORKS <br />TOTAL�3oZ <br />4j <br />PROPERTY OWNERS ARE RESPONSIBLE FOR DETERMINING ALL <br />PROPERTY LINE LOCATIONS AND RELATED EASEMENTS. <br />