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APPLICAT�ON FOft <br />�`« ""' CO�ISTR.UCT101� <br />everett PER.�wi� <br />TO BE COMPLETED IPl BLACK INK— PLEASE PRINT <br />BUILDINQ DEPT. <br />269-BT45 [I CO/AA.NATION ❑ BUILDING ❑ ME:CHANICAL <br />__..__ ...0 .nnocec r.�ri zIP <br />Cltt <br />❑ PLUMBING <br />PHONE <br />everen <br />e <br />�SIGiN <br />PLUMBINOCONTMCTOH MMLADDHESS CITY Z�P PHONE LICENSE• <br />� NEWV ^O ADDITION ❑ ALTERA710N ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPL.INSERT ❑ BUILDING RELOCATION <br />VALU�TION OF WORK�CA57 OF MATEfilAlS PLUS LABOHI <br />� ��� �� <br />OESCRIBE AK A � <br />/ <br />113E 20NE <br />I HEREBY CERTIFY THAT I HAVE REAO AND EXAMINED THIS NP- <br />PLICATION AND KNOW THE SAME TO BETRUEAND CORREC'f. ALL <br />PROVISIONS OF LAWSAND ORDINANCESGOVERNINGT111STYPE <br />OF WORK WILL BE COMPLEI'ED WITH W4ETHER SFECIF!ED HERE- <br />IN OR NOT. THE GRANTING OFl� PERMIT DOES NOT PRcSUME TO <br />GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISICNS OK <br />ANY OTHER STATE OR LOCAL LAW REGULATING CONSTRUC7ION <br />OR THE PERFORMANCE OF CONSTRUCTION. <br />SIGNAiURE OF LONTFACTOR OR AUTHORIZED AGENS DATE <br />X /��% _ _ //� //_ // i�, /.� �. /v� <br />�a <br />t.IR <br />UCENSE NU. <br />M <br />THIS PORTION TO BE COMPLETED BY BUILDING DEPT. PERSONNEL <br />REARSETBACK SIpESETBALK PLRNGHECKNUMBER PLFNLNECNFEE <br />OF <br />V�LANT SITE <br />❑YES ONO <br />AIA% OCC. 10�1D <br />�PGR.FOfl155UAN Y <br />�1 <br />FEES <br />Bl11LDING <br />PLUMBING <br />MECHANIL; L <br />OTHER <br />PENALN <br />TOTAL <br />FEE PECEIPT NO <br />VALWTION FEE <br />5 <br />