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the Evergreen <br />CITY OF <br />everett <br />BUILDING DEPARTMENT <br />259•8870 <br />� "�'' <br />APPLIC.+TION FOR CONS71��i�iCTION <br />PERMIT <br />TO BE COMPLETED IN INK— PLEASE PRINT <br />everett <br />� <br />OWNEF M1IAILAD�RE55 CITV ZIP pMONF <br />-Tgrr� c���� f�c�r;r�x.3c>� /11j,�/��s•,����F s��cti _���i-.��:: <br />TENANT MAILNDDRESS G�TY ZIP pryp�E � <br />ARCHITEGTOROESIGNER MAILADOFESS CITY 21P PMONE -�� <br />4ENEFALGONTRACTOF MAILAUORE55 CITY ZIP PMONE IICENSEr <br />�T.SNG27"C'v,vsT PORc,x i�c,� rn�aays��i�i;= ������ ��-i�sfa-�- T�rtn,ft��-2ai�� <br />MEGNANICPLCONTPACTOR AIL/ DRE55 GITY ZIP PHONE UCENSE+ <br />PWMBINGCONTRAGTOR MAILApDRE55 GITY ZIP PMONE LICENSE• <br />GL�SS OF WORK — <br />� NEW ❑ ADDITION ❑ ALTERATION O REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPLINSERT ❑ BUILDINGRELOCATION _ <br />OFWORK <br />LOT� BLOLK OF <br />7�� � <br />PLUMBING <br />OF <br />SINK 8 DISP. <br />LAUNDRYTRAY <br />CLOTHES WASHER <br />URINAL <br />DRINKING FOUNTAIN <br />FLOOR DRAIN <br />BACKFLOW PREVENTERS <br />ROOF DRAINS — RAI NLEADEfiS <br />RINKIRFFVICF—R4G FTl:1 <br />nn�n� � ncnnseien� <br />.�- �to ,�.: <br />LOTAPEA <br />'�- � <br />v — <br />INSi. pCCUPANCVI <br />E/PCTUAI <br />�_ _ i <br />. <br />Jy, � + NO.OF STOPi <br />.� <br />sF GA Z <br />KLERS REOUIPED ❑ VES ¢ NO <br />`�• F- 6-�t, <br />��---d�� <br />I HEREBV CERTIFYTHAT I HAVE READ AND EXAMINED THIS APPI.ICATION AND <br />KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISION� OF LAWS AND <br />ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE CO:NPLETED WITH <br />WHETHERSPECIFIEDHEV7EINOR NOT.THEGRANTINGOFAPE�RMI7DOESNOT <br />PFESUME TO GNE AUTHORIiY TO VIOLATE OR CAMCEL THL PROVISIONS OF <br />ANYO7HER °TH�E OR LOCAL LAW REGULA7ING CONSTRUCTION ORTHE PER- <br />FORMANCF.OF CONSTRUCTION. THAT I AM AUTHORIZED EIYTHE OWNER OF <br />THIS PROP�RNTO PERFORM THE WORK FOR WHICH APPLICATION IS MADE <br />AND I Cf�MPLY WITH THE STA7E CONTRAGTORS LAW 18.27 RCW AND <br />296AOJ WAC. <br />SiGNRTUREOFL TRACT OFAUTNOR2EDAGENT ORTE <br />X � l— 7—gn� <br />. L ANT& V USIN SSLIGENSENO.ANDBUSINESSNAME <br />MECHANICAL <br />NO. NPE OF EOI <br />nir _. erv�nini r i iuire _ <br />— B.T.U. M EA <br />WATER HEA7ER <br />WOOD STOVE <br />METAL FIREPLACE 8 CHIIANEY <br />FIREPLACEINSERT <br />HEA7 PUMP <br />GAS PIPING <br />EXHqUSTFAN <br />� ��rtE F <br />❑ NO - <br />i <br />BUILDING <br />�LIN � NITS <br />PLUMBING <br />O <br />' A MECHANICAL <br />irnyarioN OTHEF <br />SUB TOTAL <br />PERMIT <br />TOTAL FEE <br />FEE <br />3�5 <br />STA7E BUILDING SURCHARGE <br />STATE ENERGY SURCHARGE <br />PUBUC WORKS <br />TOTAL <br />5 <br />5 <br />5 <br />FEE <br />Z� <br />�? s" o <br />