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.PPLICATION FOb. evereN <br />CITY OF Me piMR CONSTRUCTION <br />ev lerett PF RBI IT e <br />TO BE COMPLETED IN BLF,CK INK— PLEASE PRINT <br />BUILDING DEPT. <br />259-8745 ❑ COMBINATION BUILDING ❑ MECHANICAL ❑ PLUMBING ❑ SIGN <br />OWN I n I.IAIL ADDRESS CITY ZIP PHONE <br />AfarPHpY, _ SSA rites i7)i 3�clilic� n2r S��/ &(,tL `1P/i� SZ7—a-OJPS" <br />ARuuTLCT OR DESIGNER MAIL ADDRESS CITY ZIP P11014E <br />AA:L ADDRESS CID ZIP PHONE LICENSE A <br />SAwT(:_ - <br />MECHANICAL CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE <br />PLUMBING CONTRACTOR MAIL A]DRESS CRY ZIP PHONE LICENSEA <br />NEVV ❑ ADDITION 9ALTERATION ❑ REPAIR ❑ DEMOLITION. ❑ WOODSTOVE/FRPL.INSERT ❑ BUILDING RELOCATION <br />VALUATION OF WORK (COST OF MATERIALS FLUS LAUGH) <br />4� 'lb <br />ash, _- <br />osscRl L <br />re,r,,-T _717 Trnln D ii <br />USE OF BUILOINO <br />nY� <br />FF to oY,o-Tl Uc, <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP- <br />PLICATION AND KNOW THE SAME TO BE TRUE 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 DOEq NOT PRESUME TO <br />GIVE AUTHORITY TO VIOLATE OR CANCEL LIE PROVISIONS OF <br />ANY OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION <br />OR THE PERFORMANCE OF CONSTRUCTION. <br />SIGNAT RE CONTRACTOR OR AUTHORIZED AGENT DATE <br />X/ 3 v l <br />LEGAL DESCRIPTION OF PROPERTYISHOWN SELOWORATTACH FOURCOPIESI <br />;OT_BLOCK _0 <br />- <br />' ) 5 /Y J 'Q <br />V A"T <br />PDO.IECT ADDRESS <br />lao, S.& . E✓fie i]—wI4/I v y <br />APPLICANTS CITY BUST SLICENSE NO <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTURE <br />FEE <br />NO. <br />TYPE OF EQUIPMENT _ <br />FEE <br />WATER CLOSE :';TOILCn_—_ <br />Z <br />AIR COND. UNITS—H.P. EA <br />BATHTUB <br />REFRIGERATION UNITS—H.P. EA. <br />_ <br />LAVATORY!WWJ BA51N) <br />BOILI?RS—H.P. EA. <br />SHOWER <br />GAS FIRED AC. UNITS —TONNAGE EA <br />KITCHEN SINK 8 DISP. <br />FORCED AIR SYSTLMS—B.T.U. M EA. <br />DISHWASHER <br />WALL HEATERS—B.T.U. M <br />_ <br />LAUNDRYTRAY <br />UNIT HEATERS—B.T.U. M <br />_ <br />CLOTHES WASHER <br />EVAPORATIVE COOLERS <br />WATER HEATER <br />C7� <br />CLOTHES DRYERS <br />URINAL <br />VENTILATION FAN <br />DRINKING FCUNTAIN <br />RANGE HOOD <br />FLOOR DRAIN <br />AIR HANDLING UNIT— C.F.M. <br />_ <br />VACUUM BREAKERS <br />STOVE <br />ROOF DRAINS—RAINLEADERS <br />_ <br />METAL FIREPLACE S CHIMNEY <br />_ <br />SINK (SERVICE —BAR, ETC.) <br />47 <br />CD <br />WOODSTOVE/FIREPLACE INSERT <br />SUB TOTAL <br />SUBTOTAL $ <br />_ <br />PERMIT S <br />PERMIT $ <br />_ <br />TOTAL FEE S <br />�` <br />-- <br />TOTAL FEE $ <br />_ <br />THIS PORTION TO BE COMPLETED BY BUILDING DEPT. PERSONNEL <br />IRONT SETBACK <br />REAR SETBACK <br />SIDE SETBACK <br />PLAN CHECK NUMBER <br />C r &Jo a <br />o L(A Vl/ <br />PLAN <br />FEE IL;l0 <br />CHECK FEE <br />RECEIPT NO <br />Ai( <br />USE ZONE <br />Cam/ <br />LOTAREA <br />4� <br />VACANT SITE <br />OYES IXN0 <br />FEES <br />ALUATION <br />FEE <br />_ <br />/}. if �p CD <br />TYPE OF CONST. <br />OCCUPANCY GROUP <br />NO. OF DWELLING UNITS <br />-D�UIL..ING <br />�C/�jt <br />s sc. <br />I— <br />-7.. <br />-1 cam <br />- <br />^SL�� <br />JV <br />SIZE OF BipG <br />yi <br />NO OF STORIES' <br />MAX. OCC. LOAD <br />PLUMBING <br />FIRE SPRINKLERS REOUIRED ❑ YES O NO <br />MECHANICAL <br />OTHER <br />PENALTY <br />APPLICATION ACC. BY <br /><t <br />PLANS CHECKED BY <br />J <br />APPR FOR ISSUANCE BY <br />L -C-• <br />TOTAL <br />/LJG <br />OC) <br />