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fhe Everpraen <br />CITY OF <br />everett <br />BUILDING DEPARTMENT <br />258•8810 <br />APPLICiw��ION FOR CONSTRV.i�T10N <br />PERMIT <br />TO BE COMPLETED IN INK— PLEASE PHINT <br />MICHITECTOHDESIONER MML�DORE59 CIIV ZIP PNONE <br />Ylew Dr. <br />1 <br />��r_ T— h�in1.� <br />❑ NEW ❑ ADDITION M� ALTEF�TION ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPL INSERT ❑ BUILOIN� RELOCATION <br />TEN�Ni IMPNOJEMENTOP INTENIOp flEMODEI ON.Y CANIAG'T P/[flSON PND PHONE NU l/ <br />CONTRI�CTPRIGEOFWORK �7J71� f�GA V�',�� n /X�� �� <br />LOT BLOCK OF <br />`�!-1'/Y � - <br />xuMsino <br />VO. TYPE OF FIXTURE OR ITEM <br />WATER CL09ET (TOILET) <br />BATHTUB <br />LAVATORV(WASH BASIN) <br />3HOWER <br />KITCHEN SINK 6 DISP. <br />DISNWASHER <br />LAUNDRVTRAY <br />_ CLOTHES WASHER <br />URINAI <br />DRINKIN� FOUNTAIN <br />FLOOR DRAIN <br />BACKFLOW PREVENTER9 <br />ROOF ORAINS— pAINLEA�EHS <br />31NKISFRVICF—Rea FTC1 <br />�LLOW�BIE/�CiU�I <br />SUB TOTAI 5 <br />PERMIT S <br />TOTAL FEE S <br />SE1B/�GN SIOES[iB�CN <br />�REA VpCANi51iE <br />❑ Y[9 O NO <br />IP�NCV6ROUP NOAFDWELUI <br />F9i0RIE5 84MT. OCGIO�L <br />❑Y <br />❑ N <br />FIRESPNINI{LE119PEOUIRED OYES ❑ <br />evcrclt <br />e <br />', I <br />_;��(n <br />LiCENSE • <br />I HEREBV CERTIFV THAT I HAVE READ AND EXAMINED THIS APPLICA'ION AND <br />KNOW THE SAME TO BC'RUF_ qND CORRECi. ALL PROVISION3 Of UWS AND <br />ORDINANCES GOVER�lING THIS TVPE OF WORK WILI BE COMPLETED WITM <br />WHETHER SPECIfIEU! iEREIN OR NOT. THE ORANTIN60FA pERMIT DOES NOT <br />Pf1ESUME i0 61VE AUTHOR�TY TO VIOLATE OR CANCEL THE PROVISIONS OF <br />ANY OTHER STATE OR LOCAL LFW REGULATINO CONSTRUCTION OR THE PER• <br />FORMANCE OF CONSTFUCTION. THAT I RM AIiTHOR12ED BV THE OWNER OF <br />THIS PROPERTY TO PERfORM THE WORK FOR WHICH APPLICAiION IS MADE <br />AND I COMPLV WITH TNE STATE CONTRACTORS LAW 18.27 RCW AND <br />298.200 WAC. <br />SION�IUREOFCONiRALtOOORAU111oRRED�UENT DATE <br />X .1-�- 5"-� %-�9 <br />�PPIICAMS CITY BUSME55 UGENSF NO �NO BUSiNE59 N1ME <br />MECH�NICAL <br />N0. ' TYPE OF EOUIP <br />A/C — A/MNDLG UNITS — M.{ <br />� FORCED AIR SYSTEMS— &7 <br />UNIT HEATERS— B.T.U. M <br />FEES <br />BUILDIN6 <br />PLUMBING <br />MECHANICAL <br />OiHER <br />STATE BUILDINQ SURCIIARGE <br />STATE ENERGY SURCH�RGE <br />PUDUC WOPKS <br />TOTAL <br />S <br />