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i�+PPLICATION FO1�.' <br />'^.EY.,O,W rett CONPERM T ION `�� <br />C�T�' OF <br />eve <br />BUILDING DEPARTMENT <br />c a-9810 TO BE COMPLETED IN INK- FLEASE PRIWT <br />❑ DEIIAOLITION ❑ COMBINATION ❑ BUILDING ❑ MECHANICAL ❑ Pl.UM81NG ❑ SIGN <br />OWNER M�IL�DDRE55 CIfV ZIP p FHON[ <br />�_/_ _ . �„� _ ' _ ,. /Y/ /YJ.�.✓.✓.�„n� ..1� / o.yn /)%Fr�vne /� �vt'-c^f i . Cri.r 9P�o9 <br />21P <br />�it��Cn��LOTFeGiOn MAI�POORESS Llrv Ziv ���ONE I�CE��S[. <br />McCNeWULGONiP�L�Oq MAIL�DORE9S G�fV 21P PMOHE UCE115E• <br />�.� 9- 9i3i <br />❑ NEW I1� <br />V�IWtIONOF WOR� <br />�ESCRIyE WOf1N <br />� �n �� �� <br />use or ew�ov�e <br />Es i r�Ei <br />LEdAL OESCf11PL0�1 <br />�o�—e�ooc.. <br />h� <br />ADDI710N ❑ ALTERATION � FEPAIR ❑ DEMOLIiION ❑ 1VOODSTOVE/FRPL.INSERT ❑ BUILDINO RELOCAIION <br />ISHOWN <br />PROJECi A0011E55 <br />'� .�._�a. /ou;�LC �o�d. <br />PLUMBING <br />NO. TYPE OF <br />WATER CLOSET �Tf <br />UR <br />LAVATpRY1WA5H BASINI <br />SHOWEA <br />K7TCMEN SINN 8 DISP. <br />DISHWASNEF <br />LAUNORVTRAV <br />CLOTHES WASHER <br />URINAL <br />DpINKING FGUNTAIN <br />FLOCF ORAIN <br />BACKFLOW PREVENTERS <br />ROOF DRAINS — RAINIEAnERS <br />SINK �SERVICE — BAR, ETC � <br />SUBTOTAL <br />PEIIMIT <br />TOTRL FEE <br />�NpN15E��ACM <br />ilSf IONE <br />rv�� OF CONST <br />S4E OF B106 <br />FIRE SPRINKLE(7: <br />4VVIiCF110YPCC B� <br />VAC�NT 9tE <br />OVES ONO <br />NO OF DWEL <br />I HEREBY CERTf�Y THAT I HAVE READ AND EXAMINED iHIS AF� <br />PLICATION AND KNOW THE SAME TO BE TRUE ANDCORRECT. ALL <br />PROVISIONS OF LAWSAND ORDINANCES GOVERNING THIS TYPE <br />OF WORK WILL BE COMPLETED WITH WHETHEH SPECIFIED HERE� <br />IN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO <br />G�VE AUTHORITY TO VIOLATE OR CANCEL TFiE PROVISIOMS OF <br />ANV OTHER STATE OR LOCAL LAW REGULATINO CONSiRUCTION <br />OR THE PERFORMANCE OF CONSTRUCTION. . <br />SIpNFTUREOFCONIR4CTORORAUiMOR�ZED/.GENT pqTE <br />�:Y� ��---�,dL....1.� �- ��- J�d' <br />7� _,:,� , <br />NO <br />MECHANICAL <br />FEE NO. TYPE OF EDUIPI <br />A/C — A/HNOLO UNITS — Ii.P. <br />REFRIGERATIDN UNITS — M.P. I <br />BOIlERS — B.T.U/H.P. <br />GAS FIRED A�C. UNITS — B.T.U. <br />FORCED AIR SYSTEMS — 9.T.0 <br />WALL HEATEPS — B.T.U. <br />UNIT HEATEFS — [1.T.U. <br />EVAPORATIVE COOLEfiS <br />CLOTNES OfiYERS <br />VENTILATICN FAN <br />RANGEHO00 <br />WATEH HEATER <br />WOODSTOVE <br />METAI FIREPLACE 8 CHIMhEV <br />FIREPLACEINSERT <br />HEATPUMP <br />GAS PIPING <br />EXHAUSTFAN <br />uv <br />� SUBTOTAL <br />PERMIT <br />TOTALFEE <br />PLAN CHECN NUM!'�' .R � FEE <br />BUILDING 5 <br />PLUMBING <br />MFrHANICAL <br />OTHER <br />STATE 6UIlDING SURCHARGE <br />STATE ENERGV SUfiCHARGE <br />Y:JBU(, :lORKS <br />TOTAL <br />M EA. <br />M <br />M <br />RECEIPT NO. <br />PROPERTY OWNERS ARE RESPONSIBLE fOR DEIERM1IINING ALL <br />PROPERTY LINE LOCATIONS AND RELATED EASEMENTS. <br />