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CITY OF f"` PLICATION FOL-" gwy k everetl <br />the Evergreen CONSTRUCTION <br />everett PERMIT <br />BUILDING DEPARTMENT <br />259.8810 TO BE COMPLETED IN INK- PLEASE PRINT <br />❑ DEMOLITION ❑ COMBINATION ❑ BUILDING ❑ MECHANICAL ❑ PLUMBING ❑ SIGN <br />OWNER MAIL ADDRESS CITY ZIP PHONE <br />CHAT Fcr'l Val q3z sc-7 z�Mw Cyo 0 5 �10 <br />ARCHITECT OR DESIGNER MAIL ADDRESS CITY ZIP PHONE <br />GENERAL ONTRACtOR JAL ADDRESS CITY ZIP PHONE 0 <br />LICENSE <br />�rochZ/`j/ /Q IU CV 659—o"0 <br />MECIIANICAI. CONTRACTOR ADDRESS • <br />CITY ZIP PHONE LICEN^-- <br />PLUMBING CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE. <br />❑ NEW ❑ ADDITION yx ALTERATION Cl REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPL.1NSERT ❑ BUILDING RELOCATION <br />VALUAT O OF _10�� 7OF MATE PLUS LABORI <br />untb�IHluc wuMll ^ Py^ �\ff\ <br />l_:S1 Of 14IND ��c WV co YJ If P)SL (\IR <br />USE OF BUILDING <br />I HEREBY CERTIFY THAT 1 HAVE READ AND EXAMINED THIS AP- <br />PLICATIONANDKNOWTHESAME TOBETRUE AND CORRECT. ALL <br />PROVISIONSOF LAWSAND 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 PERFORMANCE OF CONSTRUCTION, <br />SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT DATE <br />X I, " (o --� 4<s <br />APPLICANTS LI BUSINESS LICENSE NO <br />LEGAL DESCRIPTION OF PROPERTYISHOWN BELOWORAIIACH FOURCOPIESI <br />LOT— BLOCK OF <br />PROJECT ADDRESS <br />Ido- z S c_ <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />NO. <br />TYPE OF EQUIPMENT <br />FEE <br />WATER CLOSET (TOILET) <br />A/C — A/HNDLG UNITS — H.P. <br />BATHTUB <br />REFRIGERATION UNITS — M.P. EA. <br />LAVATORY (WASH BASIN) <br />BOILERS — B.T.U./H P. <br />SHOWER <br />GAS FIRED A.C. UNITS — B.T.U. <br />KITCHEN SIIJK A DISP. <br />FORCED AIR SYSTEMS — B.T.U. M EA. <br />DISHWASHER <br />WALL HEATERS—B.T.U. M <br />LAUNDRYTRA'I <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 GRAIN <br />RANGE HOOD <br />BACKFLOW FREVENTERS <br />WATER HEATER'S <br />ROOF DRAINS — RAINLEADERS <br />WOOD STOVE <br />` SINK (SERVICE — BAR. ETC) <br />METAL FIREPLACE A CHIMNEY <br />FIREPLACE INSERT <br />HEAT PUMP <br />GAS PIPING <br />EXHAUSTFAN <br />SUB TOTAL <br />f <br />SUB TOTAL <br />PERMIT <br />f <br />PL MIT <br />TOTALFEE <br />sl <br />TOTALFEE III <br />PLAN CHEC NUMBER <br />FEE lO <br />RECEIPT NO. <br />FEE <br />(� <br />6 L <br />FRONT SETBACK <br />REAR SE TUACK <br />SIDE SETBACK <br />USE LONE <br />Lot AREA <br />VACANT SITE <br />OYES ONO <br />FEES <br />VALUATION <br />BUILDING <br />S <br />TYPE OF LONSL <br />OLCUPANCr GROUP <br />NO. OF DWELLING UNITS <br />PLUMBING <br />SIZE OF SL DO <br />NO. OF STORIES <br />MAX. OW. LOAD <br />MECHANICAL <br />OTHER <br />3 <br />570 <br />FIRE SPRINKLERS REQUIRED ❑ YES O NO <br />STATE BUILDING SURCHARGE <br />STATE ENERGY SURCHARGE <br />APPLICATION ACC BY <br />PLANS CHECKED BY <br />APPR FOR ISSUANCE BY <br />PUBLIC WORKS <br />TOTAL <br />PROPERTY OWNERS ARE RESPONSIBLE FOR UETEHMINING ALL <br />PROPERTY LINE LOCATIONS AND RELATED EASEMENTS. <br />