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Me Evergreen <br />CITY OF <br />everett <br />CITY HALL 259 8745 <br />EVERETT. WA 98201 <br />CONSTRUCTION <br />PERMIT <br />❑ COMBINATION ❑ BUILDING QIMECHANICAL <br />PERMIT NO. 08503 <br />❑ PLUMBING <br />OWNER MAIL ADDRESS CITY ZIP PHONE <br />R.E. Pate 115 Madison Everett 98203 355-5198 <br />ARCHITECT OR DESIGNER MAIL ADDRESS CITY ZIP PHONE <br />GENERAL CONTRACTOR MAII 1DDRESS CITY ZIP PHONE LICENSE <br />Same <br />MECIIANICA'. CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE <br />PLUMBING CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE <br />S <br />❑NEW ❑ADDITION /❑ALTERATION ❑REPAIR ❑DEMOLITION El FENCE ❑SIGN ❑GARAGE <br />OF WORK <br />instal]wnnd stnve <br />PROPOSED USE OF BUILDING <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP- <br />PLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT. <br />ALL PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS <br />TYPE OF WORK WILL BE COMPLIED WITH WHETHER SPECIFIED <br />HEREIN OR NOT. THE GRANTING OF A PERMIT DOES NOT <br />PRESUME TO GIVE AU RITY TO VIOLATE OR CANCEL THE PRO- <br />VISIONS OF ANY HE STATE OR LOCAL LAW REGULATING <br />CONSTRUCTION R TV PERFORMANCE OF CONSTRUCTION. <br />SIGNATUF 10 TO dA TI AGENT DATE <br />X 10/29/80 <br />LEGALDESCRIPTIONOFPROPERTY(SHOWBELOW OR ATTACHFOUR COPIES) <br />3 A' ort Acres <br />LoT BLoc�h�P <br />JOB ADDRESS <br />115 Madison <br />PLUMBING <br />ME HANICA <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />NO. <br />TYPE OF EQUIPMENT <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. FA. <br />SHOWER <br />GAS FIRED A.C. UNITS — TONNAGE EA. <br />_ <br />KITCHEN SINK & DISP. <br />FORCED AIR SYSTEMS — B.T.U. M EA. <br />DISHWASHER <br />WALL HEATERS—B.T.U. M <br />LAUNDRY TRAY <br />UNIT HEATERS — B.T.U. M <br />CLOTHES WASHER <br />EVAPORATIVE COOLERS <br />WATER HEATER <br />CLOTHES DRYERS <br />_ <br />URINAL <br />VENTILATION FAN <br />DRINKING FOUNTAIN <br />RANGE HOOD <br />FLOOR DRAIN <br />AIR HANDLING UNIT — C'.F.M. <br />VACUUM UREAKERS <br />1 <br />STOVE Wood <br />4 <br />S <br />ROOF DRAINS -- RAINLEADERS <br />METAL FIREPLACE & CHIMNEY <br />SINK (SERVICE — BAR, ETC.) <br />SUB TOTAL <br />SUBTOTAL S <br />4 <br />50 <br />PERMIT <br />S <br />PERMIT $ <br />3 <br />00 <br />TOTAL FEE <br />$ <br />TOTAL <br />FEE $ <br />SIDE YARD SETBACK <br />STREET SETBACK <br />REAR YARD SETBACK <br />PLAN CHECK NUMBER <br />PLAN CHECK <br />FEE <br />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 />$ <br />SIZE OF BLDG. <br />NO. OF STORIES <br />MAX. OCC. LOAD <br />PLUMBING <br />FIRE ZONE <br />BASEMENT <br />FIRE SPRINKLERS <br />REQUIRED <br />DYES ONO <br />MECHANICAL <br />7 <br />50 <br />APPROVALS <br />BY <br />DATE <br />OTHER <br />1. ENVIRONMENTAL CHECKLIST <br />PENALTY <br />U.B.C. <br />SEC. 303(a) <br />2. BUILDING PLANS <br />_ <br />TOTAL <br />% <br />5 0 <br />3. FIRE HYDRANT <br />4. FIRE PROTECTION SYSTEM <br />5. GRADING <br />PERMIT VALIDATION <br />WHEN PROPERLY VALIDATED (IN THIS SPACE)THIS IS YOUR PERMIT <br />9806 $007.50-� <br />1- T} Lr <br />Oc <br />S( CI IJ R REC E I r TC <br />THANK YOU <br />6. DRAINAGE <br />7. ENVIRONMENTAL IMPACT STATEMENT <br />B. HEALTH DISTRICT <br />APPLICATION ACC. BY <br />PLANS CHECKED BY <br />APPR. FOR ISSUANCE BY <br />V.C. <br />