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} <br />the Evergreen <br />CITY OF <br />r-O N ST R U CT I O N <br />everett <br />PERMIT <br />PERMIT NO. 12191 <br />CITY HALL 2598745 <br />EVERET,, WA 98201 <br />COMBINATION XO BUILDING ❑ MECHANICAL <br />0 PLUMBING <br />OWNER <br />MAIL ADDRESS CRY <br />ZIP <br />PHONE <br />Vern W. <br />GRXXK Green 3510 Lombard Everett <br />98201 <br />252-8426 <br />ARCHITECT OR DESIGNER <br />MAIL ADDRESS CITY <br />ZIP <br />PHONE <br />GENERAL CONTRACTOR <br />MAIL ADDRESS CITY <br />ZIP <br />PHONE LICENSE N <br />Same <br />MECHANICAL CONTRACTOR <br />MAIL ADDRESS CITY <br />ZIP <br />PHONE LICENSE N <br />PLUMBING CONTRACTOR <br />MAIL ADDRESS CITY <br />ZIP <br />PHONE LICENSE N <br />❑ NEW 0 ADDITION ❑ ALTERATION &EPAIR ❑ DEMOLITION ❑ FENCE ❑ SIGN O WOOD STOVE)FIREPLACE INSERT <br />$ 720.00 <br />re -roof --metal <br />PROPOSED USE OF BUILDING <br />Single Family Residence <br />I 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 VIOLATE <br />OR CANCEL THE PROVISIONS OF ANY OTHER STATE OR <br />LOCAL LAW REGULATING CONSTRUCTION OR THE <br />PERFORMANCE OF CONSTRUCTION. <br />SIGNAT OF CONTRA OR AUTH RI DAGENT DATE <br />X -PC_ _, 9/11/83 <br />LEGAL DESCRIPTION OF PROPERTY (SHOW BELOW OR ATTACH FOUR COPIES) <br />LOT 28=2BLO BS bF Everett Div. M <br />JOB ADDRESS <br />3510 Lombard <br />PLUMBING <br />MECHANICAL <br />NO. I TYPE OF EQUIPMENT FEE <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />WATER CLOSET (TOILET) <br />AIR COND. UNITS — H.P. EA. <br />_ <br />BATHTUB <br />REFRIGERATION UNITS — H.P. EA. <br />LAVATORY (WASH BASIN) <br />BOILERS — H.P. EA. <br />SHOWER <br />GAS FIRED A.C. UNITS — TONNAGE EA <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 />WATER HEATER <br />CLOTHES DRYERS <br />URINAL <br />VENTILATION FAN <br />DRINKING FOUNTAIN <br />RANGE HOOD <br />FLOOR DRAIN <br />AIR HANDLING UNIT — C.F.M. <br />VACUUM BREAKERS <br />STOVE — WOOD <br />ROOF DRAINS — RAINLEADERS <br />METAL FIREPLACE & CHIMNEY <br />SINK (SERVICE — BAR, ETC.) <br />FIREPLACE INSERT <br />HEAT PUMP <br />SUB TOTAL $ <br />SUB TOTAL $ <br />PERMIT $ <br />PERMIT $ <br />TOTAL FEE $ <br />TOTAL FEE $ <br />SIDE YARD SETBACK <br />STREET SETBACK <br />REAR YARD SETBACK <br />PLAN CHECK NUMBER <br />PLAN <br />FEE <br />CHECK FEE <br />RECEIPT NO. <br />USE ZONE <br />LOT AREA <br />VACANT SITE <br />DYES ONO <br />FEES <br />VALUATION <br />FEE <br />TYPE OF CONST. <br />OCCUPANCY GROUP <br />NO. OF DWELLING UNITS <br />BUILDING <br />$ 720.00 <br />14 <br />SO <br />SIZE OF BLDG. <br />NO. OF STORIES <br />MAX. OCC. LOAD <br />PLUMBING <br />FIRE ZONE <br />BASEMENT <br />FIRE SPRINKLERS <br />REOUIRED <br />DYES ONO <br />MECHANICAL <br />OTHER <br />-- <br />-- <br />APPROVALS <br />BY <br />DATE <br />1. ENVIRONMENTAL CHECK LIST <br />PENALTY <br />U.B.C. <br />SEC. 303 (a) <br />2. BUILDING PLANS <br />TOTAL <br />1T45 <br />3. FIRE HYDRANT <br />4. FIRE PROTECTION SYSTEM <br />PERMIT VALIDATION <br />WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT T- . <br />9 66 $ U 14.50 - (1) <br />N <br />YOUR RECEIPT .--I <br />THANK YOU <br />S.GRADING <br />6. DRAINAGE <br />7. ENVIRONMENTAL IMPACTSTATEMENT <br />8. HEALTH DISTRICT <br />APPLICATION ACC. BY <br />PLANS CHECKED BY <br />APPR. FOR ISSUANCE BY <br />ADDRESS FILE I I A 83 <br />I <br />J <br />