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everett <br />DUILDING DEPT. <br />25"74a <br />APPLICATION FOW <br />CONSTRUCTION <br />PERMIT <br />TO BE COMPLETED IN BLACK INK — PLEASE PRINT <br />COMOINATION BUILDING W MECHANICAL P�pLUM61NG <br />Iv <br />❑ BIGN <br />JP1MtecsNsu- <br />IMd1AMCAL CONTRACTOR MAIL ADORESB CITY ZIP PHONE LICENSE A <br />PLIMIt11/GCONTR110T011 MAIL ADDRESS CITY ZIP PHONE LICENSE <br />NEW ❑ ADDITION ❑ ALTERATION ❑,REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPL. INSERT ❑ BUILDING RELOCATION <br />R�{.lA{l•{IAR <br />[��1C7'Oi1e1101Li !S'L clwYe it 13uwll y D1ECr►o�Lee�L. <br />wB OF D Nl <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AR <br />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 COMPLETED WITH WHETHER SPECIFIED H ERE - <br />IN <br />IN 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 AUTHORISED AGENT DATE <br />�Q.• <br />L�AL OESCRNRION OF PRO►EPTYISHOWN BELOW OR ATTACH FOUR COPIEBI <br />of <br />PROARESS <br />low m4r�te 4,OCW �C <br />G <br />:74ANT3 CITY BU E9 LICENS <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE Of FIXTURE <br />FEE <br />NO. <br />TYPE OF EQUIPMENT <br />FEE <br />%. <br />WATER CLOSET TOILE <br />AIR COND. UNITS-H.P. EA <br />BATNTUS <br />REFRIGERATION UNITS-H.P. EA <br />_ <br />LAVATORY (WASH WASH BASI� <br />BOILERS-H.P. EA <br />SHOWER <br />GAS FIRED AC. UNITS -TONNAGE EA <br />_ <br />KITCHEN SINK& DISP. <br />FORCED AIR SYSTEMS-B.T.U. MEA <br />DISHWASHER <br />WALL HEATERS-fl1,U. M <br />_ <br />LAUNDRYTRAY <br />UNIT HEATERS-B.T.U. M <br />CLOTHES WASHER <br />41 <br />db <br />I EVAPORATIVE COOLERS <br />WATER HEATER <br />O <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 />ROOF DRAINS-RAINLEADERS <br />METAL FIREPLACE & CHIMNEY <br />SINK SERVICE -BA ETC. <br />WOOOSTOVEIFIREPLACE INSERT <br />BUD TOTAL <br />SUB TOTAL t <br />"f• <br />�J� <br />_ <br />PERMIT • <br />PERMIT t <br />TOTAL FEE E <br />TOTAL FEE t <br />THIS PORTION TO BE COMPLETED BY BUILDING DEPT. PERSONNEL <br />FRONT SETBACK I REARSETBACK SIDES SA-K PLAN CHECK NUMBER PLAN CHECK FEE <br />LQ �� FEE �� RECEIPT NO <br />W-71 <br />OF CONST. <br />BY <br />'� 5P VACANT RATE <br />TIME& ONO <br />LNCYGROUP NO. OF OWELLIN <br />,S ; M•! ' <br />STORIES MAX OCC. LOAD <br />2 <br />C'.P,) I vkf` <br />S FEES VALUATION FEE <br />BUILUING <br />PLUMBING <br />MECIIANICAL <br />OTHER <br />PENALTY <br />TOTAL <br />