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APPLICATIQ"1 FOR CONSTRUCT''1N PERMIT � <br /> ���/ TO BE COMPLETED IN BLACK INK—PLEASE PRINT <br /> V <br /> BUILDING DEPARTMENT HEATING SYSTEM: ❑GAS ❑ELECTRIC ❑ <br /> 259-8810 <br /> ❑ DEMOLITION ❑ COMBINATION ❑ BUILDING L]MECHANICAL ❑PLUMBING ❑ SIGN <br /> OWNER MAILADORESS CITV ZIP PHONE <br /> k n�ura t L� SV�'i�as���t�/M( �/A/ n.fR���dr: /�✓aca� Nln. 9f1Q/ <br /> �NT MRIIADDRE55 CITY ZIP PHONE T� <br /> /� � � �s� E./�.: � , . ,� „ ,� , . - . , <br /> ARCMuTECTORDESIGNER MAILADDPE55 CITV ZIP PHONE <br /> '` De�f �ss i�.., �/..K,� aP....�l.l�fy �oc—�is�-o8� <br /> x NERCa�QCOyTR�CTOR � I�.RILADOREST_ / CITY ZIP P STA IICENSE� <br /> � / y�f�'3� <br /> - �DK S l,u t 1�a.+e /�o.stP /P��m�i(�K6 �1�6� /.2�IEAa .o /1/F Ltil <br /> ' ECHANICAL6�GONTRpCTOR ILADDRE55 ITV ZIP �ONE ,STAiELICENSE-� <br /> PLUMBIN6CONTR�CTOFi ���L�D�RESS CITY ZIP PNONE STATELICENSE� <br /> i <br /> �. - CONTflACTPRICEOF ORK nZ/� <br /> �/ ��4--1'{ � ,� <br /> '� � DESCPIBE RRWO �ND SOUARE F007�GE OLVE � � ONTACT SON ANO PHON� - � Yr � O O 3 <br /> ' 7,.,�6/t ra�. l' , <br /> ' � I NEREBY CERTIFY THAT I HAVE READ AND E%AMINED THIS <br /> I v use oF eui�oi APPLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT.ALL <br /> PROVISIONS OF LAWS AND ORDINANCES GOVERNINO THIS TVPE OF <br /> � �' �/IEGALDE5CR1 IONOFPROPERTY�SHOWNBELOWORATfACMTWOCOPIES) WORK WILL BE COMPLETED WITH WHETHER SPECIFIED HEfiEIN OR <br /> �. tR NOT. THE GRANTIN6 OF A PERMIT DOES NOT PRESUME TO GIVE <br /> ior e�ocrc- oF AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANV <br /> s OTHER STATE OR LOCAL LAW REGUUTING CONSTRUCTION OH THE <br /> � ` PERFORMANCE OF CONSTRUCTION.THAT I AM AUTHORI2ED BV THE <br /> � OWNER OF THIS PROPERTV TO PERFORM THE WORK FOR WHICH <br /> - � APPLICAT N IS MADE AND I COMPLY WITM THE STATE <br /> , :, 'xP11RCELTiV(I.D.NUMBER CONTR I�SLAW�H.Z� CW ND296.20DWAC. <br /> CONSTRUCTIONLWNLENCER.ADDR SS.TELEPHONENUMBER <br /> 3 <br /> PAOJECT ADDRES9 sa e o tt _ <br /> � k � e aTMau�+Ess��cEHSEra <br /> . p��y�Np MECHANICAL <br /> N0. TYPE OF flXTURE OR ITEM FEE N0. TVPE OF EGUIPMENT FEE � <br /> & WATER CLOSET(TOILET) � A/C—A/HNDLG UNITS—H.P. � <br /> BATHTUB ; FORCED AIR SYSTEMS—B.T.U. M E.A. <br /> � LAVATORY(WASH BASIN) � UNIT HEATERS—B.T.U. M �_ <br /> y SHOWEFi ' CLOTHES DRYERS � <br /> � ��� KITCHEN SINK 8 DISP I VENTILATION FAN � <br /> - DISHWASHER � RANOE HOOD � <br /> UIUNDRY TRAY ; WATER HEATER _ ' <br /> - CLOTHES WASHER � WOOD STOVE � <br /> i�, URINAL ' METAL FIREPLACE(WOC�D BURNING) ' <br /> �� DRINKING FOUNTAIN � FIREPLACE INSERT � <br /> ' FLOOR DRAM � HEAT PUMP ' <br /> !� � BACKFLOW PREVENTERS ; GAS PIPING � <br /> . ROOF DRAINS—RAINLEADERS � EXHAUST FAN � <br /> � SINK(SERVICE—BAR,ETC.) � <br /> , I <br /> � <br /> , � <br /> ' SUB TOTAL S ; SUB TOTA. E ' <br /> PERMIT $ � PERMIT $ � <br /> � TOTALFEE $ TOTALFEE $ <br /> FOR OFFlCE USE ONLY: <br /> FRONTSETBACN REARSETBACK SIDESETBALK PUNGNEC NUMBER FEE RECEIPTNO. <br /> ?� ' � � /'C� ' � Z <br /> USE ZONE LOT APJE�A + VRCANT SITE FEES VALUA710N FE _ <br /> �Z�Z �7bO— U YES ❑ NO BUILDING ��j ' <br /> 7VPE Of LONSI. NO,OF STORIES aauv�Ntv No of ow[luNGUMrts � <br /> I �wWP PLUMBING i <br /> �II � T <br /> /r <br /> SIZE OF BLDG. FIRE SPRINKLEflS flE0'D BASEMENT � MECHANICAL � <br /> J ❑ YES L�NO � <br /> � ADDITIONAL PLAN CHECK i <br /> OCCUPANCVL D FIHEALARMR OD HEIGHTLIMITATION <br /> 'J � � D Z � OTHER � <br /> PEASON � <br /> STATE BUILDING SURCHARGE � <br /> ' � <br /> INT�KE BY PUNS� P �ED BV CITY OF EYEflETT PUBLIC WORKS <br />