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':�;PPLICATION F0►`�`:': <br /> ^.verett CONPER Ui TION °`e <br /> urv or <br /> e MT <br /> BUILDING DEPARTMENT <br /> 259-8810 TO BE COMPLETED IN INK- PLEASE PRINT <br /> ❑ DEMOLITION ❑ COMBINATION � BUILDING ❑ MECHANICAL � PLUMBING ❑ SIGN <br /> OWNER M�IlA00NE55 CIIY ZIP PHONE <br /> ,/�pro/� ,�'vr��� ��I�S 1�i;��-.ar,�-�i�� ���t�� �SaO�/ �SS• 7�/p <br /> RCMiiECIONDFSiGNER M�R�OORE55 CIIY Zlo PNONE <br /> GENER�LCONIFACTON M�IL>DORE55 CI1V ZiP oNONE UCENSE• <br /> MECHANIG�CONTP�CiOfl MAIL�DOFESS CIIY ZIP PNONE LIGENSE• <br /> �!�/Zt�i� <br /> PLUM9INGLONTR�CiOP MML�O�RE55 CItY ZIV CIIONE UCENSE• <br /> CUSS Oi WORN <br /> ❑ NEW ❑ ADDIT�ON ❑ ALTERATION ❑ REPAIii ❑ DEMOLITION WOODS70VE/FRPL.INSERT ❑ BUIlOING RELOCAI�ON <br /> V�1U�110N OF WORN�COST OF M.11[RULS PW S LROOf11 <br /> ,�1.R_l.� Oa _ <br /> DESCAiBE WORK <br /> L1C�E <br /> useor aui�ou+f . � I HER[BY CERTIFY THAT I HAVE REA[' AND EXAMINED THIS AP• <br /> / � f '�' � • PLICATIONANDKNOWTHESAMETO[�ETRUEANDCORRECT.ALL <br /> LE6�LOESGNI�TiON�OFPROPERTYISHOWNBELOW fl�ITPLNfOURCOf'I[51 pROVISIONSOFLAWSANDORDINANCESGOVERNINCTHISTYPE <br /> OF WORK WILL BE COMPLETED WITH WHEThIER SPECIFIED HERE- <br /> �oi_e�ocK—or IN OR NOT.THE GRANTING OF A PERMIT DOES NOT PRESUME TO <br /> GIVE AUTHORITY TO VIOLATE OR��ANCEL THE PROVISIONS OF <br /> ANY OTH[R STATE OR LOCAL LAW REGULATING CONSTRUCTION <br /> OR THE PERFORMANCE OF CONSTRUCTION. . <br /> SIGNATURE OF CON7RACTOR OR AUTHOf1IZED AGENT pnTE <br /> X � <br /> ci�c. `�-� -�-7 <br /> VpOJECi�DDRESS �PPLiCAqYSdiT BUSINESSI�CtN5EN0 <br /> )n <br /> � I ' .L�J..�+ ,L <br /> PIUMlING MECMANICAL <br /> NO. TYPE OF FIXTURE OR ITEM FEE NO. TYPE OF EOUIPMENT F!E <br /> WATER CLOSET(TOILET) A/C—A/HNOLG UNITS—M.P. <br /> BATMTUB REFRIGEP�TION UNITS—N.P.EA. <br /> UVATORV(WASM BASIN� BOILERS—B.T.U./H P <br /> SHOWER GAS FIRED A�C.UNITS—B T.U. <br /> KITCHEN SINK d DISP. FORCEO AIR SYSTEMS—B T.U. M EA. <br /> OISMWASMER WALLHEATERS—B.T.U. M <br /> L.IUNDRY TR�Y UNIT HEATERS—B.T.U. M <br /> CIOTHES WASHER EVAPORATIVE COOLERS <br /> URINAL CLOTNE5DRYERS <br /> ORINKING FOUNTAIN VENTIUTION FAN <br /> FLOOR OHAIN � RqNGE MOOD <br /> BACKFLOW PREVENTERS WATEH NEATER <br /> ROOFDRAINS—RAINLEADEHS WOODSTOVE � <br /> SINK(SERVICE—BAR.ETCJ MEfAI FIREPLACE 8 CHIMNEV <br /> FIqEPLAGE INSERT <br /> MEATPUMP <br /> GAS PIPING <br /> E%HAUSTFAN <br /> SUSTOTAL f SUBTOT�I <br /> PERMIT f P[NMIT <br /> T0T11L FEE f TOTAL FEE <br /> iRONi SEiB�CN RE�R SETBACN SIDE SE19eCK PIAN CMECK NUMBER FEc °ECEIPT NO. <br /> use zoHe ��T�AE� ��c�r+t sire FEES VALUATION FEE <br /> DYES ONO <br /> BUILD�NG S <br /> TYPEOFCONST. OCGUP�NCYGRWV NOAf4WF.LLINQUNITS <br /> � <br /> PLUMBING <br /> SRE OF B10�. NO OF STOPIES M�%.OLG LO�D <br /> MECMANICAL <br /> OTHER <br /> FIRE SPRINKLERS REOUIRED ❑ YES ❑ NO STATE BUILOING SURCHAfiGE <br /> STATEENERGYSURCHARGE <br /> •VPIIC�IION�CC BV PL�NSCNFGNEDBV APP0.FOR155l1ANCEBY <br /> PUBIIC WORKS <br /> TOTAL <br /> PROPERTV OWNERS ARE RESPONSIBLE FOR DETERMINING ALL <br /> PROPEFNLINE LOCATIONSAND RElA7ED EASEMENTS <br />