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The Evergreen ! CONSTRUCTIONCI � Y OF <br />eyerett PERMIT PERMIT NO.OH5O3 <br />CITY HALL 259 8745 <br />EVERETT, WA 98201 ❑ COMBINATION ❑ BUILDING LQ.PECHANICAL ❑ PLUMBING <br />OWNER / MAIL ADD ESS CRY ZIP PHONE <br />R.E. Pate 115 Madison Everett 98203 355-5198 <br />ARCHITECT OR DESIGNER MAIL ADDRESS CITY ZIP PHONE <br />GENERAL CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE <br />Same _ <br />MECHANICAL CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE/ <br />PLUMBING CONTRACT09 MAIL ADDRESS CITY ZIP PHONE LICENSE# <br />S <br />DESCRIBE WORK <br />❑NEW ❑ADDITION ❑ALTERATION ❑REPAIR ❑DEMOLITION ❑FENCE ❑SIGN ❑GARAGE <br />install wood stove <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 SfAIE OR LOCAL LAW REGULATING <br />CONSTRUCTION R T PERFORMANCE OF CONSI HUCI ION. <br />SIGNATUF TO A i AGENT DATE <br />X i 10/29/80 <br />LEGALDE_KRIPrroN OF PROPERTY (SHOW BEI OW OR ATTACH FOUR COPIESt <br />3 A' Ort Acres <br />LOT aLocK_'dPP <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 />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 />_ <br />_ <br />LAUNDRY TRAY <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 />_ <br />DRINKING FOUNTAIN <br />RANGE HOOD <br />FLOOR DRAIN <br />AIR HANDLING UNIT — C.F.M. <br />VACUUM BREAKERS <br />1 <br />STOVE Wood <br />q <br />50 <br />ROOF DRAINS — RAINLEADERS <br />METAL FIREPLACE & CHIMNEY <br />SINK (SERVICE — BAR, ETC.) <br />_ <br />SUBTOTAL <br />SUBTOTAL $ <br />q <br />50 <br />PERMIT <br />$ <br />PERMIT $ <br />3 <br />00 <br />TOTAL FEE <br />SI <br />I <br />TOTAL 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 />OYES ONO <br />FEES <br />VALUATION <br />'EE <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. OGG. LOAD <br />PLUMBING <br />FIRE ZONE <br />BASEMENT <br />FIRE SPRINKLERS <br />REQUIRED <br />❑YES ONO <br />MECHANICAL <br />7 <br />50 <br />APPROVALS <br />BY <br />DATE <br />OTHER <br />1. ENVIRONMENTAL CHECK LIST <br />PENALLY <br />U.B.C. <br />SEC. 303 (a) <br />2. BUILDING PLANS <br />TOTAL <br />7 <br />50 <br />3. FIRE HYDRANT <br />4. FIRE PROTECTION SYSTEM <br />S. GRADING <br />PERMIT VALIDATION <br />WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT <br />- 9 S O 6 10 0 7. 5 0 '—' I: <br />C <br />p a <br />\I .I " , I PT C <br /><NK U <br />& 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 />9 OUT 8 0 <br />ADDRESS FILE <br />