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A r P L I C A T I O N F O R <br />(he Evergreen <br />CRY OF <br />CONSTRUCTION <br />everett <br />PERMIT <br />BUILDING DEPARTMENT <br />259-8810 <br />TO BE COMPLETED IN INK- PLEASE PRINT <br />❑ DEMOLITION ❑ COMBINATION ❑ BUILDING ❑ MECHANICAL ❑ PLUMBING <br />OWNER !1 MAIL ADDRESS CITY EUG2L 21P PHONE <br />PJ 0-7 S.E. L�-ItCE*-,-r. Mr LL- wl,y E 9E5 <br />ARCHITECTOR DESIGNER MAIL ADDRESS CITY ZIP PHONC <br />CJSIGN <br />RAAEHAp CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE <br />5 IC -I rA , <br />IOLB�Pi l2- 5, 161" Cn. II -LC. Qd-% fAIrJOFL AUF. A.ib. 5SAL.4P,,Io5 (�aZV—LI,yy3 MF.y E,.2Talgbb <br />N YIHANICAL CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE• <br />PLUMBING CONTRA( TOR MAIL ADDRESS CITY ZIP PHONE LICENSE• <br />CLA OF WORK <br />NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ bY000STOVE/FFlPL.INSERT El BUILDING RELOCATION <br />VALUATION OF WORK (COST OF M E3S.,PLUSLABORI <br />DESCRIBE WORN <br />I�STAI,L I SIF ^I=vtiL tC.L.vr✓.. SIC.-TF—I c.A-31rlCi <br />USE OF BUILDING <br />j p,V P-7 pa µ <br />1 HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP - <br />PLICA LION AND KNOWTHE SAME TO BETRUE AND CORRECT. ALL <br />PROVISIONS OF 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 <br />LEGAL DESCRIPTION OF PROPERTYISHOWN BELOW OR AITACN FOUR COP!EEI <br />LOT_BLOCK —_OF <br />PROJECT ADDRESS <br />b0-1 S.r. E�lE, >- <br />rit,C� vra <br />APPLICANTS CITY BUSNESS LICENSE NO <br />3-.?> <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTU!!E OR ITEM <br />FEE <br />NO. <br />TYPE OF EQUIPMENT <br />FEE <br />'HATER CLOSET (TOILET) <br />AIC — A/HNDLG UNITS — H.P. <br />BATHTUB <br />REFRIGERATION UNITS — H.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 SINK & DISP. <br />FORCED AIR SYSTEMS — B T.U. M EA. <br />DISHWASHER <br />WALL HEATERS—B.T.U. M <br />LAUNDRYTRAY <br />UNIT HEATERS—B.T.U. M <br />CLOTHES WASHER <br />EVAPORATIVE COOLERS <br />URII IAL <br />CLOTHES DRYERS <br />DRINKING FOUNTAIN <br />VENTILATION FAN <br />FLOOR OPAIN <br />RANGE HOOD <br />BACKFLOW PREVENTERS <br />WATER HEATER <br />ROOF DRAINS — RAINLEADERS <br />WOOD STOVE <br />SINK (SERVICE — BAR. ETC.) <br />METAL FIREPLACE & CHIMNEY <br />FIREPLACE' NSERT <br />HEAT PUMP <br />GAS PIPING <br />EXHAUST FAN <br />SUBTOTAL <br />5 <br />SUBTOTAL <br />PERMIT <br />f <br />PERMIT <br />TOTALFEE <br />S <br />TOTALFEE <br />PLAN CHECK NUMBER <br />FEE <br />RECEIPT NO. <br />FRONT SE TBAGI: <br />REAR SETBACK <br />SIDE SETBACK <br />USEZONE <br />C— I <br />LOTAF.EA <br />VACANT SITE <br />OYES ONO <br />FEES <br />VALUATION <br />FEE <br />BUILDING <br />S <br />TYPE OF CONST. <br />OCCUPANCY GROUP <br />NO. OF DWELLING UNITS <br />PLUMBING <br />SIZE OF BLDG <br />NO. OF STORIES <br />MAX. OCC. LOAD <br />MECHANICAL <br />FIRE SPRINKLERS REQUIRED ❑ YES ❑ NO <br />OTHER <br />STATE BUILDING SURCHARGE <br />STATE ENERGY SURCHARGE <br />APPLICATION ACC BV <br />PLANSCHECKED BY <br />APPR. FOR ISSUANCE BY <br />e.y-At- <br />PUBLIC WORKS <br />- <br />TOTAL <br />PROPERTY OWNERS ARE RESPONSIBLE FOR DETERMINING ALL <br />PROPERTY LINE LOCATIONS AND RELATED EASEMENTS. <br />