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APPLICATI�''1 FOR CONSTRUCT")N PERMIT <br />CITY OF EVERETT • BU!LDING DIVISION � <br />3200 CEDAR STREET • EVERtTT, WA 98201 • 259-8810 <br />❑ DENIOUTION ❑ COMBINATION ❑ BUILDING ❑ MECHANICAL ❑ PLUMBING ❑ SION <br />PROJECT ADDRESS: �s.3/S OCc�iiv A/�r <br />CITY IIP <br />A11p11T[CTORDESMaNEH I.WI�DDRE55 . LIiY 21P PHpNE <br />GENEMLCONTR�[TOR MIJL�D011E55 ptY 71P Pi10NE SGTEIICENSE� <br />AIECNANIC/�LCONTR�C•OR NIJl�DD11E55 Gtt IiP P11(WE STATEUCENSE� <br />B�S�:,St.t�.T,/,^�,?L /!s�/E.A.+�9rf'wf I//Eh� 1,lP. E�/. �an/ �S2-,�/�Y f!%7:�55/.�/1E-7 <br />PIUMlMlGCONTRACTqi MAILAWNESS GtY ZIP PNONE $T�TEIILEN$E• <br />� <br />MVOWED <br />ior xoac <br />MqCEl TAk I.D. MIYBEfl <br />CONSTRIICTp/ IOAN LENOER. AOORE55. TELEPIId1E M14lER <br />OF FlIlTURE OR ITEM <br />BATHTUB <br />CLOTHES <br />UNINAL <br />BACKFLOW PREVENTE� <br />SINK (SERVICE — BAR, <br />FOR OFFICE USE ONLY: <br />F110NTSETBAGf RE�RSET&1GN <br />NEIGNT IIAqTATIp/ <br />FlI1E <br />IOT�REA <br />SUB TOTAL S <br />PERMIT S <br />TOTALFEE f <br />SIDE SETB�Ck <br />NO OF DWELLIH6 <br />UNIiS <br />V�CMlT SIIE <br />❑YES <br />5�2E OF BIDGRI <br />HEATING SYSTEM: �GAS ❑ ELECTRIC ❑ <br />I HEREBY CERTIFY TMAT 1 HAVE REAO AND EXAMINED THIS <br />APPLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT ALL <br />PROVISIONS OF UWS AND ORDINANCES GOVERNING THIS TYPE OF <br />WORK WILL BE COMPLIED WITH WHETHER SPECIFIED HEREIN OR <br />AOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO 61VE <br />AUTHORITY TO VIOLATE OR CANCEL THE PROVISION OF ANV <br />OTHER STATE OR LOCAL lAW REGULATINO CONSTRUCTION OR THE <br />PERFORMANCE OF CONSTRUCTION. THAT I AM AUTHORIZED BV THE <br />OWNER OF THIS PROPERTY TO PERFO�iM THE WORK FOR WHICH <br />APPLICATION IS MADE AND I COMPLY WITH THE STATE <br />CONTRACTO 5 LAW 1' 27 RCW AND 296.200 WAC. <br />x c�,..���- d- � s� <br />SN3N�TURE O�TE <br />��_ <br />___Q. <br />BS,� <br />_���I <br />���� <br />TYPE OF EWIPMENT <br />flANGEHOOD <br />WATER HEATER <br />WOOD STOVE <br />FIREPLACE <br />RANGE <br />PUNQIEGRMINBER IEF <br />FEES <br />❑ NO pUII�IHf. <br />❑YES ❑ NO <br />CITV OF EVERETT <br />LOCAL SALES <br />TAX CODE IS 9105 <br />PLUMBING <br />MECN�NiC�I <br />�DdilON�l PUN GNF.CK <br />OtNEP <br />STQE BUIIUINfi SIIRCH�nCE <br />ruaur.woaKs <br />TOTAL <br />SUB TOTAL S <br />PERMIT f <br />TOTAIFEE f <br />RFf.EIPT'10 <br />n <br />