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IMPLICATION FOf�'*% <br />c <br />theEvergreen <br />CITY OF <br />CONSTRUCTION <br />59'-1 <br />%�1���,/7 I <br />/ <br />�Y�T`n <br />eKverett <br />PERMIT <br />/ <br />BUILDING DEPARTMENT <br />259.8810 <br />TO BE COMPLETED IN INK- PLEASE PRINT <br />❑ DEMOLITION <br />O COMBINATION ❑ BUILDING ff MECHANICAL <br />❑ PLUMBING <br />0 SIGN <br />OWNER <br />MAIL ADDRESS CITY ZIP <br />PHONE <br />I <br />Pi S'F4 `Y �' IY� S j �i0� :7i:'e✓P/Pi� tV Gilt, <br />F <br />ARCHITECT OR DESIGNER <br />MAIL ADDRESS CITY 21P <br />PHONE <br />GENERALCONIRACIOR <br />MAIL ADDRESS CITY ZIP <br />PHONE <br />LICENSE• <br />2v�n� <br />MCONTRACTOR <br />~I MAIL AOPPE53 CITY ZIP <br />PHONE <br />LICENSE• <br />/I/A I�SUA/ AA/( <br />F'#T /Ah- <S 'f -D 0P'5Ul Ly.yn/i"oor, Ku/,- gPa 3 N <br />27511-1529 <br />TT(ICkl-oi 4 <br />IrECHANICeL <br />_............................ <br />UAII AnnnP[R CITY ZIP <br />PHONE <br />LICENSE <br />led NEW ❑ ADDITIUN ❑ ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPL.INSERT ❑ BUILDING RELOCATION <br />VALUATONOFWp OSIOFMATERIALSPLUSkABORT <br />DESCRIBE WORK n / <br />USE OF BUILDING <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP- <br />PLICATIONAND KNOWTHESAME TOBETRUE 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 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 AUT ORIZED AGENT DATE <br />r <br />LEGAL DESCRIPTION FPROPERTYISHO44- WN BELOW OR ATTACH FOUR COPIES( <br />LOT— BLOCK. --OF <br />PROJECT ADDRESS <br />1 S - P6 <br />No <br />APPLICANTS CO BUSINESB UCE ISE NO <br />PLUMBING <br />If <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/HNOLG UNITS — H.P. <br />BATHTUB <br />REFRIGERATION UNITS — H.P. EA. <br />_ <br />LAVATORY ( WASH BASIN) <br />BOILERS — B.T.U./H. P. <br />SHOWER <br />GAS FIRED A.C. UNITS — B.T.U. <br />KITCHEN SINK A DISP, <br />FORCED AIR SYSTEMS — B.T.U. M EA, <br />DISHWASHER <br />WALL HEATERS—B.T.U. M <br />LAUNDRY TRAY <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 />V <br />RANGEHOOD <br />BACKFLOWPREVENTERS <br />WATER HEATER <br />ROOF DRAINS — RAINLEADERS <br />WOOD STOVE <br />SINK (SERVICE — BAR. ETC.) <br />METAL FIREPLACE S CHIMNEY <br />FIREPLACE INSERT <br />HEAT PUMP <br />GAS PIPING <br />EXHAUST FAN <br />SUBTOTAL <br />S <br />SUBTOTAL <br />PERMIT <br />S <br />PERMIT <br />TOTAL FEE <br />S <br />TOTAL FEE <br />PLAN CHECK NUMBER <br />FEE <br />RECEIPT NO. <br />FEE <br />TAUNT SETDACK <br />REAR SETBACK <br />SIDE SETBACK <br />USE ZONE <br />LOTAREA <br />VACANT SITE <br />OYES ONO <br />TEES <br />VALUATION <br />BUILDING <br />S <br />TYPE OF CONST. <br />OCCUPANCYGROUP <br />NO. OF DWELLING UNITS <br />PLUMBING <br />SIZE OF BLDG. NO. OF STORIES MAK OCC. LOAD <br />FIRE SPRINKLERS REQUIRED O YES ❑ NO <br />MECHANICAL <br />OTHER <br />STATE BUILDING SURCHARGE <br />STATE ENERGY SURCHARGE <br />APPLICATION ACC BY <br />\x ` - <br />PLANS CHECKED By <br />APPR. FOR ISSUANCE BY <br />/ <br />PUBLIC WORKS <br />TOTAL <br />F YHUYGHI T <br />PROPERTY LINE LOCATIONS AND RELATED EASEMENTS. <br />