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1 <br />�tiPPLICATION F� <br />'�:« "'" CONSTRUCTION <br />�verett PERMIT <br />BUILDING DEPARTMENT TO BE COMPLETED IN INK • PLEASE PRINT <br />268•8810 <br />❑ DEMOLITIa�N ❑ COMBINATION ❑ BUILDING ❑ MECHANICAL <br />OWNER M�IL�OORE55 ��TM Z <br />� sr��v��5 �►1c���Z ki� � ��� - t�l � � � i � 1C��{� F.�����«_ . ( � ��(� <br />❑ PLUMBING ❑ SIGN <br />PHONE <br />� f.� rhF ���r�� `1 �a � <br />GENEMLGONTRAGTOR MAii�0UPE55 C��Y 21P PHONE LICENSE• <br />MECM�NIG�IGONTN�CTOq M�IL�OORE55 CITY ZIP PHONE LILENSE• <br />��n-,-� innr-�nnA <br />ZIP <br />.___._... N,�17LtPf\L �-' ��`� ��Cl'ilE� �� � �) r.� k I � K1-U'lt� l,� Cl [�� �fJl=. , C.C�cll.cl ,�,7Xd��! �/ / <br />CLASS OF WORK <br />❑ NEW ❑ AD.7ITION Q ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPL.INSEFT ❑ BUILDING RELOCATION <br />VQ WTION OF WONN IGOST OF M�fEHULS P�U$ L�90R1 <br />E WORN p � <br />-'�1 �'J�!'ZL�\ C � � _ l � Ic <br />U6E <br />�V 1 � � :�r � <br />.�� <br />PLUMBING <br />f�� <br />6 OISP. <br />CLOTHES <br />URINAL <br />DR�INS - <br />SUSTOTAL s <br />PEXMIT f <br />TOTALFEE f I <br />FpONTSETB�LN RE�RSE78�GN SIOESETBACK <br />USEIONE LOTAREA y�CANTSiiE <br />OYES ONO <br />fYPEOFCON9T. OCGUP�NCYGROUP NO.OF�WELLINQIINITS <br />SIZEOF9LDO NO.OFSfOAlE9 MR%.OLQLO�O <br />FIRE SPRINHLERS REOUIFED O VES ❑ NO <br />�PP4CATION AGG. BY PL�NS L'NEGNEO BY �PP0. FOP 195U�NGE 6Y <br />���Z�Q�. ��\ <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP• <br />PLICATION AND KNOW THE SAMETO BETRUEANDCORRECT.ALL <br />PROVISIONSOF LAWSAND ORDINANCES GOVERNINGTHISTYPE <br />OF WORK WILL BE COMPLETED WITH WHETHER SPECIFIED HERE• <br />IN OR NOT. THE GRAN7ING OFA PERMITDOES NOT PRESUMETO <br />GIVF AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OK <br />ANY OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION <br />OR THE PERFORMANCE OF CONSTRUCTION. . <br />SIGNATURFOFCONTApCTORORAUTMORIZEDAGENT 04TE <br />A �� � � <br />�PPLIC�NT9 C11Y BUSiME <br />MECHANICAL <br />NO. TY <br />,vc - nnao�c <br />REFRIGERATION UNITS — H.P. EA. <br />BOILERS — B.T.U./H.P. <br />GAS FIREC A.C. UNITS — B.T.U. <br />FORCE� AIR SYSTEMS — B.T.U.�JS)`M <br />WALLMEATERS—B.T.U. M <br />UNITHEATERS—B.T.U. M <br />CLOTHESDRYEFS <br />VENTILATION FAN <br />RANGEHOOD <br />WATER HEATER <br />WOODSTOVE <br />METAL FIREPLACE 6 CHIMNEY <br />CIREPLACE INSERT <br />P�PINO <br />1UST FAN <br />PLAN CMECK NUMBER <br />SUB TOTAL <br />PCflMIT <br />TOTALFEE <br />IFEE <br />BUILOING 5 <br />PLUMBING <br />MECHANICAL <br />OTHER <br />STATE BUILDING SURCHAFiGE <br />STATEENERGYSURCHAFGE <br />PUBLIG WORKS <br />TOTAL <br />RECEIPT NO. <br />PfiOPEPTV OW NERS AFiE RF.SPONSIBLE FOR DETERMINING ALl <br />PROPERN LINE LOCATIONSAND RELATED EASEMENTS. <br />., .,.._ ......_.... ... _. . : <br />. :�`.,'"�...""_.....� : . . � .. . . . <br />