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APPLICATIr''�1 FOR CONSTRUC�9N PERMIT � <br />��� TO BE COMPLETED IN BLACK INK—PLEASE PRINT <br />HEATING SYSTEM: ❑ GAS ❑ ELECTRIC ❑ <br />BUILD�NG DEPARTMENT <br />259•8810 � <br />❑ DEMOLITION ❑ COMBINATION ❑ BUILDING ❑ MECHANICAL ❑ PLUMBING ❑ SIGN <br />OWNEfl f ( P�<fyry- MAILADDRESS GITV ZIP PMONE �.rO'� <br />�o�ac �7rrp�,ss �4.B�K P5' £^.7`n���r�s k�r �n2d l-6�F�' r' ,•r <br />TENANT y MFILADDRE55 CITY ZIP PHONE <br />21P PHONE <br />I�lStldO,'n c/T�'�'Sc //'oYrLS d/d =�'�' / l�r "q JP!!//c� wh 7Qlb(.,_�7IY/�/CfI /61�7Q _ <br />GENER L C�+ TRACiOR �M tL ADDRE55 C3I ZiP oqONE STATE LICENSE �� <br />�.2S�lat.�S;e ��v.d (.0�0 /looaJf� ✓�/�a5e �i�naati � /l���te� ���a �-'i.�•S'�" <br />MECMANICALCONTRACTOR MRI ADDRESS CITY ZIP PHONE STATELICENSE• <br />(,�N-� i l{.�.�. D 7 !v .0 / <br />PLUM9ING CONTFACTOR M�IL pDDFE55 CITV ZIP PHONE STATE LICENSE � <br />CIXJTRACT PRI OF WORK <br />ct'S�o�- �. I S o <br />DESCRIBE WORK AND SOURRE FOOTR E INVOLVED <br />PflOPOSED U�� II <br />LEGAL DESCRIPTI� <br />LOT��Y <br />� <br />sT <br />PARCE TAXID.NUMBE <br />corr Tnucnorrw� i <br />PROJECTADDRE: <br />�. ��_n . <br />PflOPERTV �SHOWN BE�OW Ofl <br />BLOCN � OF i <br />-vl'�- aoc <br />R.ADDRESS.TELEPNONE <br />C�:;l <br />WATER CLOSET (TOIL <br />BATHTUB <br />LAVATORY�WASH BA: <br />SHOWER <br />KITCHEN SINK & DISP <br />DISHWASHER <br />UUNDRV TRAY <br />CLOTHE� WASHER <br />URINAL <br />DRINKING FOUNTAIN <br />FLOOR DRAIN <br />BACKFLOW PREVENT <br />ROOF DRAINS—RAINI <br />FOR OFFICE USE ONLY: PG <br />FRONTSETBACK REAPSETBRGN <br />� . � _. <br />1`— <br />iYPEO�FC�ON5�1�. <br />—Jl�L` <br />SREOFBIDG. <br />1 YO � <br />OCCUPnNCYL <br />N <br />FERSON <br />INTAKE BY <br />�o. <br />� <br />CONTACT PERSON AND PHONE NO. <br />r <br />i HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS <br />� APPLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL <br />PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE OF <br />COPIESI WORK WILL BE COMPLETED WITH WHETHER SPECIFIED HEqEIN OR <br />NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE <br />AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS UF ANY <br />I.µ • S OTHER 5TATE OR LOCAL LAW REGULATING CONSTRUCTION OR THE <br />PERFORMANCE OF CONSTRUCTION. THAT I AM AUTHORIZED BY THE <br />_�`P� OWNER OF THIS PROPERTY TO PERFORM THE WORK FOR WHICH <br />APPLICATION IS MADE AND I COMPLY WITH THE STATE <br />CONTRACTORS LAW 18.27 RCW AND 296.200 WAC. <br />TOTAL FEE $ � <br />�W O� $�✓`i�K.r <br />SIDE SETBACK / <br />� <br />FIRE SPRINN`LE/RS REO'D <br />N 0 <br />FIRE ALf.RM REO�� <br />OnTE <br />NO. TYPE OF EUUIPM <br />AIC-A/HNDLG UNITS-H.P. <br />FORCED AIR SYSTEMS-B: <br />UNIT HEATERS-B.T.U. M <br />CIOTHES DRYERS <br />VENTILA'ION FAN <br />RANGE 1106C <br />WATER HEATER <br />WOOD STOVE <br />METAL FI�iEPLACE (WOOD <br />FIREFJICE INSERT � <br />HEAT PUMP <br />GAS PIPING <br />EXHAUSTFAN <br />M E.A. <br />SUB TOTAL <br />PERMIT <br />TOTAL FEE <br />Z10 U <br />6� YES ❑ NO gUiLDiNG <br />acuvr,ecr xoorwrtuixcuxns <br />�" °3 PLUMBING <br />BRSEMENT � MECHANICAL <br />❑ YES �NO <br />HEIGMT LIMITATION ADDITIONAL PLAN CHECK <br />Z , OTHER <br />STATE BUILDING SURCHARGF <br />CITY OF EYERETT PUBLIC W�RKS <br />LOCALSALES <br />TAl( COOE IS 3105 TOTAL <br />v <br />FEE <br />/U7 <br />a <br />•I <br />� <br />