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APPLICATIO.� FOR CONSTRUCTI.IN PERMIT <br /> TO BE COMPLETED IN BLACK INK—PLEASE PRINT � <br /> �ATING SYSTEM: �� GAS CI ELECTRIC �.1 <br /> BIIILDING DEPARTM�NT <br /> 259-8810 <br /> -' DEMOLITION i! COMBINATION f ; BUILDING '� MECHANICAL ❑PLUMBItdG Ll SIGN <br /> OWNER MNILADDRE55 C:T\ 21P PHONE <br /> �t1-�� U�G C�d,� l ��=�_(�n� � . �1?..��i�+ ���s-3 - - <br /> TENA MI+IL AODRE55 CITV ZIP P ONE <br /> AR MREGTOROESIGNER MAILlDORE55 CITY ZIG PHCNE <br /> �(�(�, (�I�r�}��-�' 7�on IFf� ?��� rr �f�( T�'z-�7o� �� i�Ifll03� <br /> GENERA�CONTRqCTOR IAFILA�ORESS CITY ZIP PHONE STA1ELiCENSEu <br /> MECHAWCFLWNiRACTOR MAILAO�REFS CITV ZIP PHONE STATELICENSGa <br /> PLUMBMGGONTRACTON MAILAO�FESS CRY ZIP PHONE STATELILENSE< <br /> CONTRAC RICE(�W^ORK <br /> �C�/ <br /> DESCRIBE N DSOOAREFQpTpGEINVO ED CONTACiPEP50'��PHO NO j�( � ��� �/a/ <br /> � ��/ <br /> I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED 7HIS <br /> PROPOSED USE OF BUILDING APPLICATION AND KNOW 7HE SAME TO 0[TRUE AND CORflECT.ALL <br /> PRGVISIONS OF I.AWS AND ORDINANCES GOVERNING THIS TYPE OF <br /> �eca�oescaianor+oFPqoaearvisNowNeE�owoaatrncHnvocoaiEsi WORK WILL BE COMPLETED WITH WHETHER SPECIFIED HEREIN OR <br /> NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE <br /> �oT OLOCN oF AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY <br /> OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION OR THE <br /> PERFORMANCE OF CO TION.THAT I AM A RIZED BY THE <br /> OWNER OF THIS R T 0 PERFOR E WOR FO WHICH <br /> APPLICATI I D PLV WIT S?ATE <br /> vaace�rnx i.o.NurneEa CONTPACT A 8 W AN 6.200 WAC. <br /> � � <br /> CONSTRIJCTION LOAN LENDER.AODFESS.TELEPHONE 4UMBE r� <br /> PROJECT ADDRESS �ic�.r.��c o �(�� <br /> %O�� /A/11,� (�/ rGU. �' � cirro�su�Ess��- NSF � — � <br /> PLUMBING MECHAt:I kC <br /> N0. TYPE OF FIXTURE OR ITEM FEE NO. TYPE OF EOUIPMENT FEE <br /> WATER CLOSET(TOILET) NC—A/HNDLG UNITS—H.P. � <br /> BATHTUB FORCED AIR SY5i EMS—B.T.U. -�vt E.A. <br /> LAVATORY(WA$H BASIN) UNIT HEATERS—B.T.U. M <br /> SHOWER � CLOTHES DRYERS <br /> KITCHEN SINK 8 DISP ; VENTILATION FAN ' <br /> -T <br /> DISHWASHER � RANGE HOOD _ <br /> LAUNDRY TRAY WATER HEATER _� <br /> CLOTHES WASHER � VJOODSTOVE � <br /> URINAL ' METAL FIREPLACE(WOOD BURNING) ' <br /> URINKING FOUNTAIN FIREPLACE INSERT <br /> FLOOR DRAIN HEAT PUMP � <br /> BACKFLOW PREVENTERS ; GAS PIPING <br /> ROOF DRAINS—RAINLEADER.^, EXHAUS'FAN <br /> SINK(SERVICE—BAR,ETC.) . <br /> � <br /> � <br /> SUB TOTAL S ; SUB TOTAL 5 _ <br /> PERMIT 5 PERMIT 5 � � <br /> TOTAL FEE 5 TOTAL PEE 5 �''' <br /> FOR OFFICE USE ONLY: <br /> PRONTSET04CK REARSET6ACK SIOESETBACK PLFNCHEC NUTAEIER FSE RECEIPTNO. <br /> � ,,� <br /> usezoNe LOTAPEA vneaNrsite FEFS VALUATION FEE <br /> ' YES . , NO BUILDING <br /> iYPEOFC@lSi. NO.OFS'ORIES OCtu.aSc �o0ro'nFu�:iccurts i <br /> cnacc PLUMBING <br /> � <br /> SIZEOFBLDG. �FlfiESPRINKlER5RE0'D BASEMENT , MECHANICAL _ 1 <br /> —! YES NO ��� ���� <br /> OCCUPANCV�OAD I FIRE ALAiihl REO'D MEIGHT LIMRATION ADDITIONAL PLAN CHECK i <br /> I � <br /> _L OTHER � <br /> � <br /> REASON <br /> STATE BUILDING SURCHAFGE <br /> iNTAN[�� PLANSFFPROVEDBY CITYOFEUERETT PU�LICWORKS <br /> LOCAL SALES — <br /> DAiE TAR CODE IS 3105 TOTAL <br />