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APPLICATION FGA <br />PvcTeN <br />the Evergreen <br />Citt OF <br />CI <br />CONSTRUCTION <br />�1 <br />I- <br />ewerett <br />PERMIT <br />10 BE COMPLETED IN BLACK INK - PLEASE PRINT <br />BUILDING DEPT. <br />259.3745 <br />ry <br />INATION ❑ BUILDING I:c:J MECHANICAL <br />El COMBT <br />❑ PLUMBING ❑ SIGN <br />OWNER <br />MAIL ADDRESS CITY ZIP <br />%dua- U�)L' S ' l i r irA'ET% <br />PHONE <br />ISA, 1�.� (J { �55 27`✓ <br />2 <br />AACHITECT9RDESIGNER %11K. /� y('-,' MAIL ADDI'RESEjS[ CITY / 1P <br />�,INJ/., <br />PH O NE <br />CITY <br />CLASSOF WORK <br />❑ NEW ❑ ADDITION LM ALTERATION L❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPLANSERT ❑ BUILDING RELOCATION <br />VALUATION OF WORK (COST OF MATERIALS PLUS LABOR) <br />DE CHIDE WORK �i,,. Arr• T ;'_..�.. r< ia.; r.L:[J A/1/Grf'� f✓Ri1 (.vc/-i",� J/Prr �h/lt C 7Ci;U <br />rk-n-nce (--r1M/1/r jLl�,�� -u „� " 1- /"- <br />- .._._- _ -. 1,I ,, ._ <br />USE OF BUILDING r1 _ <br />I HEREBY CERTIFY THAT I HAVE READ AND EX. '11NED THIS AP- <br />,y,4zK-,ljko t6 / �' /�f+��j/fT <br />PLICATIONAND KNOWTHESAMETO BE TRUE AND CORRECT. ALL <br />PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE <br />DESCRIPTION OF PROPERTY(SHOWN BELOW OR ATTACH FOUR COPIES) <br />LEGAL <br />OF WORK WILL BE COMPLETED WITH WHETHER SPECIFIED HERE- <br />IN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO <br />10 VIOLATE OR CANCEL THE PROVISIONS OF <br />GIVE AUTHO'r11TY <br />ANY OTHFR STATE OR LOCA: LAW REGULATING CONSTRUCTION <br />OR THE PERFORMANCE OF CONSTRUCTION. <br />SIGNATURE OF CONTRACTOR OR AUT HORIZED AGENT DATE <br />APPL NTSCITYBUSINESS L NEE NO. <br />IcPROJECT <br />ADDRESS <br />f <br />a911IF f S 1 ![JUG <br />MECHANICAL <br />PLUMBING <br />TYPE OF FIXTUflE <br />FEE <br />NO. <br />TYPE OF EQUIPMENT <br />FEE <br />NO. <br />AIR COND. UNITS-H.P. EA. <br />WATER CLOSET )TOILET) <br />REFRIGERATION UNITS-H.P. EA <br />BATHTUB <br />BOILERS-H.P. EA <br />_ <br />LAVATOR/)WASHBASIN) <br />C. UNITS -TONNAGE E <br />GAS FIRED A.G. <br />_ <br />SHOWER <br />FORCED AIR SYSTEMS-B.T.U. M EA. <br />SINKB DISP. <br />WALL HEATERS-B.1.U. M <br />UNIT HEATERS-B.T.U.M <br />fDISH%VASHER <br />NDRY TRAY <br />EVAPORATIVE COOLERS <br />THS WASHERCLOTHES <br />DRYERS <br />ER HEATER <br />VENTILATION FAN <br />URINAL <br />RANGE HOOD —_ <br />DRINKING FOUNTA114 <br />AIR HANDLING UNIT- C.F.M. _ <br />FLOOR DRAIN <br />STOVE <br />VACUUM BREAKERS <br />METAL FIREPLACE E CHIMNEY <br />ROOF DRAINS-RAINLEADERS <br />INSERT <br />SINK SERVICE -BAR. ETC.)-WOODSTOVFJFIREPLACE <br />SIIR TOTAL $ <br />SUB TOTAL <br />PEHMII 3 <br />PERMIT E <br />TOTAL <br />TOTALFEE <br />TOTAL FEE S <br />_S <br />THIS PORTION TO BE COMPLETED BY BUILDING DEPT. PERSONNtL <br />