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i <br />iV'PLICATION FOR:-), <br />theCAE OF CONSTRUCTION e <br />everett PERMIT <br />BUILDING DEPARTMENT 259.8810 TO BE COMPLETED IN INK • PLEASE PRINT <br />❑ DEMOLITION ❑ COMBINATION O BUILDING ❑ MECHANICAL ❑ PLUMBING ❑ SIGN <br />OWN E II MMI ADDRESS CIIY bF PHONE <br />Qr � jt zrC �� ��rfC� Cyrr�� Lv, lz2v 3s 3J80$' <br />-__...- ....... ..,.,.o - MUL ADDRESS CIIY ZIP PHONE <br />OE NI'RALCONIRACIOn <br />MAR ADDRESS"'" •"•"•� """'-"' <br />CIE ~�`-- <br />MML ADDRESS CITY ZIP PHONE LICENSE • <br />MECIIANIGL C "AC7011 <br />PLUMBING CONIR:.,106 <br />MAIL ADDRESS CITY ZIP PHONE LICENSE <br />CLASS OI WORK <br />❑ NEW ADDITION ❑ ALTERATION Cl REPAIR ❑ DEMOLINON ❑ WOODSTOVE/FRPL.INSERT ❑ BUILDING RELOCATION_ <br />VALUATIONOF WORN6^SIOF MAIER ALS PLD DO"$ <br />7�oo 4 <br />DESCRIBE WORK 11 <br />USE OF BUILDING J_ <br />Ca <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP - <br />A �� <br />PLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL <br />PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE <br />LEGAL DESCRIPTION OF PROPERTY ISHOWN BELOW OR Al1ADH FOUR COPIESI <br />OF WORK WILL BE COMPLETED WITH WI IETHER SPECIFIED HERE- <br />LOT_BLOCIL_OF <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 <br />OFOF CC/p��,IRRAAACCCTTTOR OR AUTHORIZED .ENT DATE <br />zo <br />Xird7 <br />PROJECT ADDRESS <br />APPLICANTS CIIY BUSINESS LICENSE NO <br />I PLUMBING <br />MFCHANICAL <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />NO. <br />TYPE OF EQUIPMENT <br />FEE <br />WATER CLOSET (TOILET) <br />A/C — A/HNDLG UNITS — H.P <br />I '• <br />BATHTUB <br />REFRIGERATION UNITS — H P. EA. <br />LAVATORY (WASH BASIN) <br />BOILERS — B.T.0 /H P. <br />SHOWER <br />GAS FIRED A.C. UNITS -- S.T.U. <br />KITCHEN SINK S DISP. <br />FORCED AIR SYSTEMS — B T.U. M EA. <br />DISHWASHER <br />WALL HEATERS—B.T.U. M <br />LAUNDRY TRAY <br />UNIT HEATERS — B T.U. M <br />CLOTHES WASHER <br />EVAPORATIVE COOLERS <br />URINAL <br />I <br />CLOTHES DRYERS 71 <br />j <br />DRINKING FOUNTAIN <br />VENTILATION FAN <br />F <br />I <br />FLOOR DRAIN <br />RANGE MOOD <br />F, <br />BACKFLOW PREVENTERS <br />WATER HEATER . <br />ROOF DRAINS — RAINLEADERS <br />WOOD STOVE <br />Ium <br />METAL FIREPLACE 8 CHIMNEY <br />FIREPLACE INSERT <br />HEAT PUMP <br />OAS PIPING <br />EXHAUSTFAN <br />SUB TOTAL <br />PERMIT <br />TOTAL ET'E <br />S <br />TOTAL FEE <br />PLAN CHECI NUMBER <br />19970 <br />FEE <br />�:9 <br />RECEIPT NO. <br />;IRONY SETBACK, <br />REAR SETBACK <br />SIDE 5E1[iACM, / <br />Y <br />USE to <br />Qom, <br />j <br />LOI AREA <br />VACANT SITE <br />�-6 UYEB <br />FEES <br />VALUATION <br />FEE <br />• <br />L l l- 1 ` <br />$ <br />BUILDING <br />tt"' OF COUST <br />OCCU,'ANC1 GROUP <br />NO OF DWFLLING UNITS <br />- Aj •• N <br />/w <br />PLUMBING <br />S1ZE OF SLOG <br />NO OF STORIES <br />MAX OCC LOAD <br />MECHANICAL <br />S Fir to, <br />I <br />m* <br />OTHER <br />STATE BUILDING SURCHARGE <br />FIRE SPRINKLERS REQUIRED ❑ YES . NO <br />STATE ENERGY SURCHARGE <br />APPLICATION ACC !1Y <br />FUNS CHECKED BY <br />API'R FOR 135UANLE BY <br />PUBLIC WORKS <br />TOTAL <br />PROPERTY LINE LOCATIONS AND RELATED EASEMENTS. <br />