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the fv CITTYYOOF ONSTRUCTIO* <br />CITY <br />everett PERMIT PERMIT NO. 15861 <br />CITY HALL 259-8745 <br />EVERETT. WA 98201 COMBINATION ❑ BUILDING %❑ MECHANICAL ❑ PLUMBING <br />OWNER MAIL ADDRESS CITY ZIP PHONE <br />Robin Bernhoft 1030 North Park Dr. Everett 98203 252-1940 <br />ARCHITECT OR DESIGNER <br />MAIL ADDRESS CITY ZIP PHONE <br />GENERAL CONTRACTOR <br />MAIL ADDRESS CITY ZIP PHONE LICENSE <br />MECHANICAL CONTRACTOR <br />MAIL ADDRESS CITY ZIP PHONE LICENSE N <br />PLUMBING CONTRACTOR <br />MAIL ADDRESS CITY ZIP PHONE LICENSE 0 <br />CLASS OF WORK <br />❑ NEW ❑ ADDITION Cl ALTERATION <br />❑ REPAIR ❑ DEMOLITION ❑ FENCE ❑ SIGN n WOOD STOVEIFIHEPLACE INSERT <br />VALUATION OF WORK <br />S 1500.00 <br />DESCRIBE WORK <br />Install Fireplace Insert <br />PROPOSED USE OF BUILDING <br />Single family residence <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS <br />APPLICATION AND KNOW THE SAME TO BE TRUE ANDCORRECT. ALL PROVISIONS OF LAWS AND ORDINANCES <br />GOVERNING THIS TYPE OF WORK WILL BE COMPLIED WITH <br />WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A <br />PERMIT DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE <br />OR CANCEL THE PROVISIONS OF ANY OTHER STATE OR <br />LOCAL LAW REGULATING CONSTRUCTION OR THE <br />PERFORMANCE OF CONSTRUCTION. <br />SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT DATE <br />X 12/23/85 <br />LEGAL DESCRIPTION OF PROPERTY (SHOWBELOW OR ATTACH FOUR COPIES( <br />LOT -BLOCK -OF <br />JOB ADDRESS <br />1030 N Park Dr <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />N0. <br />TYPE OF EQUIPMENT <br />FEE <br />WATER CLOSET (TOILET) <br />AIR COND. UNITS — H.P. EA. <br />BATHTUB <br />REFRIGERATION UNITS — H.P. EA. <br />LAVATORY (WASH BASIN) <br />BOILERS — H.P. EA. <br />SHOWER <br />GAS FIRED A.C. UNITS — TONNAGE EA. <br />KITCHEN SINK 8 DISK <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 />WATER HEATER <br />CLOTHES DRYERS <br />URINAL <br />VENTILATION FAN <br />DRINKING FOUNTAIN <br />I RANGE HOOD <br />FLOOR DRAIN <br />AIR HANDLING UNIT -- C.F.M. <br />VACUUM BREAKERS <br />STOVE — WOOD <br />ROOF DRAINS — RAINLEADERS <br />METAL FIREPLACE 8 CHIMNEY <br />SINK (SERVICE — BAR, ETC.) <br />X <br />FIREPLACE INSERT <br />7 <br />50 <br />HEAT PUMP <br />SUB TOTAL <br />$ <br />SUB TOTAL $ <br />PERMIT <br />$ <br />PERMIT $ <br />9— <br />TOTAL FEE <br />$ <br />TOTAL FEE $ <br />17 <br />150 <br />SIDE YARD SETBACK <br />USE ZONE <br />TYPE OF CONST. <br />SIZE OF BLDG. <br />STREET SETBACK <br />REAR YARD SETBACK <br />PLAN CHECK NUMBER <br />PLAN <br />FEE <br />CHECK FEE <br />RECEIPT NO. <br />FEE <br />LOT AREA <br />VACANT SITE <br />.YES NO <br />FEES <br />VALUATION <br />OCCUPANCY GROUP <br />NO. OF DWELLING UNITS <br />BUILDING <br />S <br />NO, OF STORIES <br />MAX. OCC. LOAD <br />PLUMBING <br />FIRE ZONE BASEMENT <br />APPROVALS <br />FIRE SPRINKLERS <br />REQUIRED <br />YES NO <br />MECHANICAL <br />17 <br />50 <br />— <br />OTHER <br />BY <br />DATE <br />1. ENVIRONMENTAL CHECK LIST <br />PENALTY <br />U.B.C. <br />SEC. 303 (a) <br />50 <br />2. BUILDING PLANS <br />TOTAL <br />17 <br />3. FIRE HYDRANT <br />4. FIRE PROTECTION SYSTEM <br />65. . DRAINAGE <br />7. <br />7. ENVIRONMENTAL IMPACT STATEMENT <br />8. HEALTH DISTRICT <br />APPLICATION ACC. BY PLANS CHECKED BY <br />M. M. <br />PERMIT VALIDATION <br />WHEN PROPERLY VALIDATED ON THIS /S�gG�I THIS �5 xO�RiPEriMIJT <br />y (f <br />T� E� 1� LL7 <br />APPR. FOR ISSUANCE BY I',,) ! I R "E C E I ` T'I-4 <br />7: °.'!P, YCU <br />Z l� UEL' 8 <br />ADDRESS FILE <br />