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Me Evergreen <br />CITY OF C-INSTRUCTION - ogm�;� irt nPERMIT PERMIT zs9-aaoo Q _--18033 <br />❑ DEMOLITION ❑ COMBINATION a BUILDING ❑ MECHANICAL ❑ PLUMBING ❑ SIGN <br />OWNER �- MAIL ADDRESS CITY ZIP PHONE <br />Dorothy Ellege 3423 Lombard Everett 98201 259-2792 <br />ARCHITECT OR DESIGNER MAIL ADDRESS CITY ZIP PHONE <br />GENERAL CONTRACTOR <br />MAIL ADDRESS <br />CITY <br />ZIP <br />PHONE LICENSE <br />Everett Bldrs. <br />5606 Evergreen Way <br />Everett 98203 <br />353-7161 <br />EVEREB*301PH <br />MECHANICAL CONTRACTOR <br />MAIL ADDRESS <br />CITY <br />ZIP <br />PHONE LICENSE <br />PLUMBING CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE+ <br />❑ NEW ❑ ADDITION Cl7 ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ BUILDING RELOCATION <br />5267.00 <br />Roof tear off and reroof (14 sq. comp.) 4RA siding (12sq.) <br />HEAT SOURCE <br />❑ ELECTRICITY ❑ GAS ❑ WOODSTOVE Cl OTHER <br />PROPOSED USE OF BUILDING <br />Single SAt family residence <br />1 HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS <br />APPLICATION AND KNOW THE SAME TO BE TRUE AND <br />CORRECT. ALL PROVISIONS OF LAWS AND ORDINANCES <br />GOVERNING THIS TYPE OF WORK WILL BE COMPLIED WITH <br />WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A <br />PERMIT DOES NOT PRESUME TO GIVE AUTHORITY TO <br />VIOLATE OR CANCEL THE PROVISIONS OF ANY OTHER <br />STATE OR LOCAL LAW REGULATING CONSTRUCTION OR <br />THE PERFORMANCE OF CONSTRUCTION. <br />SITU OF CONTRACTOR. UTHORIZED AGENT. OR OWNER DATE <br />X ti / 8 <br />LEGAL DESCRIPTION OF PROPERTY (SHOW BELOW OR ATTACH FOUR COPIES) <br />LOT _ BLOCK _ OF <br />JOB ADDRESS <br />3423 Lombard <br />PLUMBING <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/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 B DISR <br />FORCED AIR SYSTEMS —B.T.0 MEA. <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 />URINAL <br />CLOTHES DRYERS <br />DRINKING FOUNTAIN <br />VENTILATION FAN <br />FLOOR DRAIN <br />RANGE HOOD <br />BACKFLOW PRE'JENTERS <br />WATER HEATER <br />ROOF DRAINS — RAINLEADERS <br />WOOD STOVE <br />SINK (SERVICE — BAR, ETC.) <br />METAL FIREPLACE & CHIMNEY <br />FIREPLACE INSERT <br />HEAT PUMP <br />GAS PIPING <br />_ <br />EXHAUST FAN <br />SUB TOTAL <br />$ <br />SUBTOTAL <br />PERMIT <br />$ <br />PERMIT <br />TOTALFEE <br />$ <br />TOTAL FEE <br />FRONT SETBACK <br />REAR SETBACK <br />SIDE SETBACK <br />PLAN CHECK NUMBER <br />FEE <br />RECEIPT NO. <br />USEZONE <br />LOTAREA <br />VACANTSITE <br />❑YES ONO <br />FEES <br />FEE <br />TYPE OF CONST. <br />OCCUPANCY GROUP <br />NO. OF DWELLINGUNCS <br />BUILDING <br />EVALUATION <br />ON 000A44d) <br />N.n .t::c <br />PLUMPING <br />, <br />SIZE Of BLDG <br />NO. OF STORIES <br />MAX OCC. LOAD <br />MECHANICAL <br />ELDO L <br />1.00 <br />FIRE SPRINKLERS REQUIRED ❑ YES Cl NO <br />INVESTIGATION FEE <br />304(e) <br />^•5(t <br />STATE BUILDING SURCHARGE <br />ST1TE ENERGY SURCHARGE <br />APPLICATION ACC. BY <br />S.H. <br />PLANS CHECKED By <br />gppR, FOR ISSUANCE <br />BY <br />DRIVEWAY PERMIT <br />TOTAL <br />az <br />so <br />WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT <br />CM <br />CY'D <br />co <br />ADDRESS FILE <br />