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CONSTRUCTION <br />PERMIT APPLICATION <br />COMBINATION • BUILDING • MECHANICAL • PLUMBING <br />OWN�E%R1�,[�/1j'-'�/ 1( f - MAIL ADUHL:bti <br />ZIP PHONE <br />O� <br />/ <br />- / <br />ARCHITECT OR DESIGNER <br />ILAODRESS <br />LICI,NSk NU <br />GENERAL CONTRACTOR <br />MAIL ADDRESS <br />PHONE LICENSE NU. <br />MECHANICAL CONTRACTOR <br />MAIL ADDRESS <br />PHONE LICENSE NO. <br />►:.UMBING CONTRACTOR <br />MAILADDRESS <br />PHONE LICENSE ND. <br />PERMIT <br />CLASS OF WORK <br />❑COMBINATION <br />❑ BUILDING []PLUMBING Q MECHANICAL <br />❑N[W <br />14ADDITIDN ❑ALTE RATION ❑HLI'N FI <br />VALUATION OF WORK---- <br />-��— <br />/ <br />[I DEMOLISH <br />❑FENCE ❑SIGN 0':1VIMMIN(: POOL. <br />S 00 <br />DESCRIBE WORK <br />PROPOSED USE <br />OTHER PERMITS OR APPROVALS <br />_ <br />/cam/ C <br />11 RE ZONE tj SPECIAL USE <br />- <br />LEGAL DESCRIPTION OF PROPERTY tSHOW BELOW OR ATTACH <br />FOUR COPIES <br />-.y, 0-l1 g�3 9 <br />LOT BLOCK_OF <br />- — - <br /># VARIANCE tj SNORLINE <br />1>7bp <br />SE PA CHECK LIST REQUIRED <br />1� YES <br />1:7 NO <br />J�Y`' <br />JOB ADDRESS <br />MECHANICAL <br />PLUMBING <br />TYPE <br />NO. <br />OF ENERGY <br />_ _ TYPE OF EOUIPM_ENT _.............. <br />_ FEE <br />—+S <br />AIR COND. UNITS-H.P. EA, 1 <br />RtF RIGERANDN UNITS NP�EA —�— <br />OOII ERS N.P EA.-----�— IL_ I <br />FORCED AIR SYSTEMS B.T.U. MEA. �— <br />-- --- - <br />I <br />SPACE & WALL HEATERS - TA <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />HAIR THUS <br />S <br />CLOTHES YlA SHtlt <br />' <br />DISH WASHEItS - <br />I <br />DEUNKING FOUNTAINS <br />FIOOH DRAINS <br />I <br />KITCHEN SINKS & 01j' <br />1 <br />'UNIT HEATERS H.T.V 1 <br />IIAn SINKS <br />I <br />1 EVAPORATIVE_COOLE HS �— <br />- <br />IIOOF DRAINS RAIN LEADERS <br />I <br />ICLOTIES DR ERS-----_—I <br />1 <br />SHOYJEH RATH5 <br />VENTILATION FAN I <br />SERVICE SINKS <br />RANGE HOOD i I <br />SUMPS - SEWAGE PUMP <br />I <br />-- <br />UnINAI$ <br />I <br />AIR HANDLING UNIT D.F.M. <br />CLOSETS <br />I-- <br />_ _WATER <br />_ WATER HEATE{IS - ELECTRIC <br />I <br />_WATER HEATER - <br />WASH BASINS- <br />1 <br />FAC. BUILT FIREPLACE #6 CHIMNEY I <br />LAUNDRY TRAYS <br />GAS. SYSTEM: NO OP OUTLt IS !— -r-- <br />._____ SUBTOTAL <br />' <br />PERMIT <br />SUB TOTAL <br />' <br />PERMIT <br />S <br />THIS PE FiMIT IILC OM ES NUIL AND VON) II WO11K I1R CO NST RUC <br />— TOTAL FEE <br />TION AVTIIORIZED IS NOT COMMLNCLO WITHIN 120 UAYS, OR IF <br />CONSTRUCTION OR WORK IS. SU;IPFNDED OR ABANDONED FOR A <br />WATER SERVICE SIZE BLDG <br />SUPPLY SIZE <br />PERIOU OF 120 DAYS AT ANY TIME AE TER WD(IK I!: COMMENCED. <br />Sc U.. K ST( IUACK <br />HLAHYA USt IdACL, <br />/q <br />F <br />SAVE REAOIII, AND EXAMINED Nr. AP <br />I NCREIIV CERTIFY KNOW <br />PsnvE% oN AND KNOW THE SAME TO 11C THUS AND ING RFCT. ALES <br />IONS OF OI NOES GUV ERNING THIS TYPEI <br />- <br />�GIFI/ L <br />//� <br />/-� F <br />OF WO E C PLI WIT14 <br />OF WORK WILL BE COMPLIED WITH WHETHER ::P[CI FILD HEREIN <br />USE ZU k LUT AN A <br />VACANT SITE <br />OR NOT, TILE GRANTING OF A PERMIT DOES NOT PRESUME TOI <br />G <br />DYES <br />GIVE AUTOOn ITY TO VIOLATE OR CANCEL THE PROVISION$ OF <br />ONO <br />ANY OTHER STATE OR LOCAL LAW 91LOULATINIi CONSTFIUCTION <br />TYPE UE CONST. OCCUPANCY GROUP NO. OF DWELLING <br />OR THE PERFORMANCE OF CONSTRUCTION <br />UNITS <br />512E OF BLDG. NO. OF S ORIES <br />MAX. OCC. LOAD <br />-/INk LONE IIA[a MLNI <br />/Ilil .51'IiINKILIiS <br />SIGNATV EO FCONTRACTORORAUTILAGENT F. <br />i Y - <br />RfOUINEU <br />❑YES ONO <br />YL•_.N L-Ht NUMIILH "LAN LIILCK I LL <br />PLC RECEIPT NO <br />SPECIAL CONDITIONS. <br />/j /J <br />FEES VALUATION FEE <br />----- <br />BUILDING�— <br />SEPA REVIEW COMPLETE DYES ❑ NO <br />PL IIMIIINI: <br />Conlatl Plannlnq dept. <br />MLCMANICAL 1 <br />• <br />OTHER I <br />I <br />Anua nu'. ��uruu •. .ur>Inli•(u �. <br />!u'4Vvloluel I_q♦ <br />PENALTY SEC. 300111$ 1 <br />TOTALit <br />Fr <br />