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the Evergreen APPLICATION FOR evereH <br />CITY OF ..0NSTRLJCT`'dON n <br />everett PERI <br />i"f <br />DEPT. OF COMMUNITY DEVELOPMENT SERVICES -� <br />CITY HALL 259-8745 <br />EVERETT, WA98201 ❑COMBINATION ❑ BUILDING ❑MECHANICAL ❑PLUMBINr PERMIT NO. <br />OWNER 11 MAIL ODRFSE CITY Zm PHOM <br />Jou1.1 UDu¢or 4(aZl u6cr hue P430ma.r - 9B14* 1SZ-91K0 <br />ARCHITECT OR DESIGNER MAIL ADDRESS CITY ZIP YHVNL <br />GENERAL CONTRACTOR MAIL ADDRESS CITY 21r PHONE LICENSE F <br />CLASS OF WORK <br />❑NEW ❑ADDITION ❑ALTERATION ❑REPAIR ❑DEMOLITION ❑FE 4CE ❑SIGN ❑GARAGE ❑BUILDING RELOCATION <br />VALUATION OF WORK <br />S <br />DESCRIBE WORK <br />1171 — - _ __ - <br />PROPOSED USE OF BUILDING <br />LEGAL DESCRIPTION OF PROPERTY )SHOWN BLOW OR ATTACH TOUR COPIES) <br />LOT _BLOCK__OF <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP- <br />PLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT ALL <br />PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE <br />OF WORK WILL BE COMPLIED WITH WHETHER SPECIFIED HEREIN <br />OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO <br />GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF <br />ANY OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION <br />OR THE PERFORMANCE OF CONSTRUCTION. <br />SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT DATE <br />j <br />TOR ADDRESS ILL <br />GA <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTURE <br />FEE <br />NO. <br />TYPE OF EQUIPMENT <br />FEE <br />WATER CLOSET (TOLIET) <br />IAIR <br />COND. UNITS —HP EA <br />BATHTUB <br />REFRIGERATION UNITS—H.P. EA <br />LAVATORY (WASH BASIN) <br />BOILERS—H.P. EA <br />SHOWER <br />GAS FIRED AL. UNITS —TONNAGE EA <br />KITCHEN SINK A DISP <br />FORCED AIR SYSTEMS—B.T.U. M EA <br />DISWASHER <br />WALL HEATERS-0 IF M <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 />DRINKING FOUNTAIN <br />RANGE HOOD <br />FLOOR DRAIN <br />AIR HANDLING UNIT— C F.M. <br />VACUUM BREAKERS <br />STOVE <br />_ <br />ROOF DRAINS —RAINLEADERS <br />METAL FIREPLACE A CHIMNEY <br />SINK (SERVICE —BAR. ETC) <br />L 1135STT <br />_ <br />SUB TOTAL <br />SUR TOTAL 7 <br />PERM17 <br />S <br />PERMIT 7 <br />7OTALFEE <br />S <br />TOTAL FEE S <br />SIDE YARD SETBACK <br />STREET SETBACK <br />REAR YARD SETBACK <br />PLAN CHECK NUMBER <br />PLAN <br />Ill <br />CHECK FEE <br />RECEIPT NO. <br />USE ZONE <br />LOT AREA <br />VACANT SITE <br />DYES ONO <br />FEES <br />VALUATION <br />FEE <br />_ <br />TYPE OF CONST <br />OCCUPANCY GROUP <br />NO OF DWELLING UNITS <br />BUILDING <br />S <br />SIZE OF BLDG <br />NO. OF STORIES <br />MAX OCC. LOAD <br />PLUMBING <br />FIRE ZONE <br />BASEMENT <br />BEDROOMS <br />FIRE SPRINKLERSREQUIRE <br />❑YES ONO <br />MECHANICAL <br />APPROVALS <br />BY <br />DATE <br />OTHER <br />1. ENVIRONMENTAL CHECK LIST <br />PENALTY <br />L 0 <br />qc to Jlal <br />2. BUILDING PLANS <br />TOTAL <br />7 FIRE HYDRANT <br />A FIRE PROTECTION SYSTEM <br />PERMIT VALIDATION <br />WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT <br />S GRADINGIEXCAVATION IS CLEARING/GRUBBING <br />6. DRAINAGE <br />7. ENVIRONMENTAL IMPACT STATEMENT <br />HEALTH DISTRICT <br />APPLICATION ACC. BY <br />PLANS CHECKED BY <br />APPR. FOR ISSUANCE BY <br />u. 1 71, A <br />