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P M . <br /> CITY HALL 259�B745 <br /> EVERETT.VJA 98207 ❑ COMBINATION ❑ BUILDING ❑ MECHANICAL PLUMBING <br /> , lAAILADDRE55 CIiY ZIP VMONE <br /> ' OYlNER /ti <br /> Jack M. Hen:y 1602 Dull Place � , � ti <br /> ARCHITEGT OP OESIGNER 1/41L A�DRE55 CITV ZIP PHONE _�-\ <br /> � GENERAL GONTRALTOR <br /> MAI�ADDRE55 CITY ZIP PHONE UCENSEI <br /> AIECMANIGPL CANTiUCTOR <br /> MAIL ADORESS CITY ZIP PHONE LIGENSE t <br /> PLUlA91NG CANTRACTOR <br /> MAIL AD�RE55 CITY 21P PHONE LICENSE I <br /> Same <br /> GlF55OF WORK <br /> + ❑NEW ❑ADDITION ❑ALTERATION ❑F7EPAIR ❑DEMOLITION ❑FENCE ❑SIGN GARAGE <br /> VALUATION OF VJOFlK <br /> b <br /> DESCRIBE WORK <br /> replace water lines <br /> PRCPOSED USE OF BUIL�ING <br /> I HEREBY CERTIFY THAT I HAVE REnD AND EXAMINED THIS AP- <br /> �Ecn�oEseeiar�aNOFaaoPearr�sNowee�owoan**ncHFouacoviesi PLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT. <br /> AL� PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS <br /> �or BLOCK_OF TYPE OF WORK WILL BE COMPLIED WITH WHETHER SPECIFlED <br /> HEREIN OR NOT. THE GRANTING OF A PERMIT DOES NOT <br /> PRESUME TO GIVL-AUTHORITY TO VIOLATE OR CANCEL THE P90� <br /> VISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATIN4 <br /> CONSTRUCTION OR THE PERFORMANCE OF CONSTRUCTION. <br /> SIGNAtUR[OF CONTRPCTOB OR PUTMORRE�AGENt DAiE <br /> �oo nooaEss ���L 1/9/81 <br /> 1609 Lombard X � <br /> HANICAL <br /> PIUMBING <br /> NO. TYPE OF FIXTURE OR ITEM FEE NO. TYPE OF E(IUIPMENT FEE <br /> WATER CLOSET(TOILEn AIR COND.UNITS—HP. EA. <br /> REFRIGERATION UNITS—H.P.EA <br /> BATHTUB <br /> BOILERS—H P.EA. <br /> L4VATORY(WASH BASIN) <br /> GAS FIRED F.G. UNITS—TONNAGE EA. <br /> SHOWER <br /> FORCED AIR SYSTEMS—�.T.U. M EA. <br /> � KITCHEN SINK 8�ISP. <br /> DISHWASHER WALL HEATERS—B T.U. M <br /> UNIT HEATENS—B.T.U. M <br /> LAUNGriY TRAY <br /> EVAPORATNE COOLERS <br /> CLOTHES WASHER CLOTHES DFYERS <br /> WATEP HEATER <br /> � URINAL VENTILATION FAN <br /> PANGFHOOD <br /> DRINK�NG FOUNTAIN CF.M. <br /> AIR HANDLING UNIT— <br /> FLOOR DRAIN STOVE <br /> VACUUM BREAKERS <br /> ROOF DRAINS—RAINLEADERS <br /> h1ETAL FlREFIACE 8 CHIMNEV <br /> SINK 15ERVICE—aAa.ETC.1 <br /> .a er Line Z <br /> SUB TOTAL 2 � SUB TOTAL S <br /> S PERMIT S <br /> PEFMIT 707AL FEE 3 <br /> 70TALFEE S 5 O <br /> PLAN CHECK FEE <br /> SIDE YARD SETBACK STREET SETBACK REAR YARD SETBACK PLAM CHECK NUMBER FEE RECEIPT NO. <br /> USE ZONE LOT AREA VACANT SITE FEES V:.IUATION FEE <br /> ❑YES ❑NO — <br /> TYPE OF CONST. OCCUPANCV GROUP N0.OF DWELLING UNITS <br /> BUILDING � <br /> SIZE OF BLUG. NO.O�STOFIES MAX.OCC.LOAD pLUMBING S 00 <br /> FIFEZONE BASEMENT FIRESPRINKLERS MECHANICAL <br /> FEOUIREU <br /> ❑YES ❑NO <br /> APPHOVALS <br /> BY DATE OTHER <br /> 1. ENVIRONMENTAL CHECK LIST PENALTY U.B.C. <br /> SEC.3031a) <br /> 2. BUILDINGPIANS TOTA� S 00 <br /> 3. FIRE HYDRANT <br /> PEHMIT VALIDATION <br /> n. FIRE PROTECTION$YSTEM \NHEN PFOPERLY VALIDATED(�N THIS SPACE)THIS IS Y(O�UR PERMIT _����] <br /> S. GRADING � C � 3 .UC O J. CO �J <br /> G. DRAINAGE �. <br /> Z ENVIRONMENTALIMPACTSTATEMENT � QO <br /> e. HEALTH DISTRICT � �� � ��)I� <br /> APPR.FORISSUANCE BY � ` : t� <br /> APPLICATION ACC.BY PLANS CHECKED BY , . .� �,♦ 1 L <br /> I / ,_,,; U I <br /> ADDRESS FILE <br />