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the Evergreen A• PLICATION FOR r,F rrll <br />CITY OF CONSTRUCTION <br />everett P E R NA I T <br />r BUILDING DEPT.TO BE COMPLETED IN BLACK INK — PLEASE PRINT <br />259.8745 ❑ COMBINATION ❑ BUILDING ❑ MECHANICAL ❑ PLUMBING ❑ SIGN <br />VECHAFRCAL CONTRACTOR <br />MAIL ADDRESS <br />CRY <br />ZIP PHONE LICENSE <br />75MBING CONT"CTOR <br />MAI, ADDRESS <br />CITY <br />ZIP PHONE LICENSEA <br />-.pSS OF WORK <br />�-- <br />❑ NEW ❑ ADDITION P4 <br />ALTERATION ❑ <br />REPAIR ❑ OEMOLITION <br />❑ WOODSTOVE/FRPL.INSERT ❑ BUILDING RELOCATION <br />rALIPOON Or WORK (COST OF MATERIALS PLUS LACORI <br />'rt SLNIB WORK <br />=oAl1T A J <br />OAiN91TlAl). <br />fie--Lf 491(w11 <br />'1 :E OF BJILDING -- <br />I HEREBY CERTIFY THAT I HAVE READ AN, GXAMINED THIS AP- <br />PLICATION AND KNOW THE SAME TO BE TRUEANDCORRECT.ALL <br />PROVISIONS OF LAWSAND OFIDINANCES GOVERNING THIS TYPE <br />OF WORK WILL BE COMPLETED WITH WHE FHEH SPECIFIED HERE- <br />IN OFI NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO <br />GIVE AUTHOHIIY TO VIOLATE OR CANCEL THE PROVISIONS OF <br />ANY OTFIER STATE OR LOCAL LAW REGULATING CONSTRUCTION <br />OR THE PERFORMANCE OF CONSTRUCTION. <br />SIGN F OFCON7RACTORORAUIFIORIZEDAGEN7 DATE <br />/ a•-- L <br />APPLICANTSCNY BU'l'IF 1W I Ila NSF NO \ \ITir , <br />fOAT DESCRIPTICINOFPROPERTY 1SIIOWNBELOW ORATTACH FOUR COPIES, <br />11 _eLGcr_oF <br />'+It it rt ppIH+E St `` " C L T 'mot �'�_ �4_'t / 1 <br />- C- T 'T.._ <br />PLUMBING <br />MECHANICAL <br />_ NO. <br />TYPE OF FINTURG <br />FEE <br />NO. <br />TYPE OF EOUIPME_NT <br />FEE <br />_ <br />WATER CLOSET(TOILEP <br />_ <br />AIR COND. UNITS-H.P. EA. <br />BATHTUB <br />REFRIGERATION_ UNITS-H. P. EA <br />LAVATORY(WASH BASIN) _- <br />BUILERS-_H P. EA.-'—_-__—__--_ <br />---- <br />SHOWER <br />_ _ <br />GAS FIRED A C. UNITS -TONNAGE EA <br />KITCHEN SINK& DISP. <br />FORCED AIR SYSTEMS-B.T.U. M EA. <br />_ <br />DISHWASHER <br />WALL HEATERS-B.T.U. <br />LAUNDRY TRAY <br />_M_ <br />UNIT HEATERS-B.T.U. M_____ <br />CLOTHES WASHER <br />EVAPORATIVE COOLERS <br />WATER HEATER <br />CLOTHES DRYERS__ <br />URINAL <br />_ <br />VENTILATION FAN <br />DRINKING FOUNTAIN <br />_ <br />RANGE H000 <br />FLOOR DRAIN _ <br />AIR HANDLING UNIT- C.F_M. <br />VACUUM BREAKERS <br />_ <br />STOVE <br />ROOF DRAINS-RAINLEADERS <br />METAL FIREPLACE 8 CHIMNEY <br />SINK SERVICE -BAR. ETC. <br />WOODSTOVE/FIREPLACE INSERT <br />----__ <br />- <br />SUB TOTAL <br />__ .__.._._____. <br />PERMIT__ S <br />-_--_---_-TOTAL FEE $ <br />___ <br />PERMIT S <br />._ <br />TOTAL FEE S <br />_ <br />THIS PORTION TO BE COMPLETED <br />BY BUILDING DEPT. PERSONNEL <br />FRONT SETBACK <br />REARSETSACK <br />SIDE SETBACK <br />PLAN CHECK NUMBER <br />PLAN <br />CIIECK FEE <br />` . I33 <br />V Y\ �J// <br />FEE / /v� <br />RE[C�3�1{O315 <br />// <br />/ C <br />✓ <br />USEZONE <br />. <br />LOT AREA <br />yACANT SITE <br />DYES ONO <br />FEES <br />VALUATION <br />FEE <br />rYPEOFCONST. <br />`J_ I uTl <br />OCCUPANCYGROUP <br />NO OF CWELLING UNITS <br />BUILDING <br />f l� <br />WlE OF SLOG <br />0 f i <br />NO. OF STORIES <br />I <br />MAX. OCC. LOAD <br />PLUMBING <br />� � <br />FIRE SPRINKLERS REQUIRED Il!'�'ES ONO <br />MECHANICAL <br />OTHER <br />APPLICATION ACC BY PLANS CKECKED BY <br />APPR FOR ISSUANCE BY <br />PENALTY <br />__— <br />Jry <br />TOTAL <br />I%Q <br />i <br />al <br />a <br />