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the Evergreen <br />CITY OF <br />everett <br />BUILDING DEPARTMENT <br />259-8810 <br />.gym. PIW. <br />APPLICATION FOR CONSTRJCTION <br />PERMIT <br />TO BE COMPLETED IN INK — PLEASE PRINT <br />OWNER MAIL ADDRESS CITY ZIP PHONE <br />ARCHITECT OR DESIGNER MAIL ADDRESS CITY 21P PHONE <br />N 17�r��T f/�J R8�d3 'ASS= v�Ol) <br />GE RAL CONTRACTOR (lMAIL ADDRESS CITY 21P PHONE LICENSE• <br />,J F)<fL Uc FTr I CI $ZO % 0 %{/65zi M / <br />C ANICAL CONTRACTOR MAI ADDRESS CITY Im _ <br />PLUMBING CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE <br />CLASS OF WORK <br />0 NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPL INSERT ❑ BUILDING RFI OCATIEIN <br />TENANT IMPROVEMENT OR INTERIOR REMODEL ONLY <br />CONTRACT PRICE OF WORK <br />OLD <br />CO/NT`ACT PERSON AND PHONE NO [/ <br />C.�' p '� 7- q s / <br />DESCRIBE WORK AND SQUARE FOOTAGE V 0 <br />i L <br />—fJ <br />P SED USE OF BU ILDING <br />-- <br />1 H EREBY CERTIFY THAT I HAVE READ AND EXAMI N ED THIS APPLICATION AND <br />KNOW THE S AME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS AND <br />ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLETED WITH <br />SPECIFIED HEREIN OR NOT.THE GRANTING OFA PERMITOOES NOT <br />PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF <br />ANY OTH ER STATE OR LOCAL LAW REGULATING CONSTRUCTION OR THE PER- <br />FORMANCE OF CONSTRUCTION. THAT I AM AUTHORIZED BY THE OWNER OF <br />THIS PROPERTY TO PERFORM THE WORK FOR WHICH APPLICATION IS MADE <br />AND I COMPLY WITH THE STATE CONTRACTORS LAW 16.27 RCW AND <br />296.200 WAG, <br />SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT DATE <br />X 4 �,� <br />APPLICAN CITYB IN ESSLICENSENO. ANDBUSINESSNAME <br />LEGAL DESCRIPTION OF PROPERTYISMOWN BELOW OR ArtACH FOUR CONTEST <br />LOT BLOCK OF / 7 <br />c m7s S'f4;, Rik, 1d_6_F <br />,�cfy Tdl us go1). <br />PROJECT ApDRE <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />NO. TYPE OF EQUIPMENT <br />FEE <br />WATER CLOSET (TOILET) <br />— <br />A/C - A/HNDLG UNITS -H.P. <br />BATHTUB <br />FORCED AIR SYSTEMS-B.T.U. M EA <br />LAVATORY (WASH BASINI _ <br />UNIT HEATERS-B.T.U. M 116760p <br />SHOWER <br />•) <br />CLOTHES DRYERS <br />KITCHEN SINK & DISP. <br />VENTILATION FAN <br />DISHWASHER <br />RANGE HOOD <br />LAUNDRY TRAY <br />WATER HEATER <br />CLOTHES WASHER <br />In— <br />WOOD STOVE <br />URINAL <br />METAL FIREPLACE 8 CHIMNEY <br />DRINKING FOUNTAIN <br />FIREPLACE INSERT <br />FLOOR DFAIN <br />HEAT PUMP <br />_ <br />BACKFLOW PREVENTERS <br />GAS PIPING <br />ROOF DRAINS— RAINLEADERS <br />EXHAUST FAN <br />SINK(SEPVICE— BAR, ETC.) <br />SUBTOTAL <br />$ <br />cy— <br />SUBTOTAL S <br />A <br />PERMIT <br />$ <br />PERMIT S <br />-:— <br />TOTAL FEE <br />$ <br />L- <br />— <br />TOTAL FEE $ <br />FRONT SETBACK SETBACK <br />20' <br />REAR SETBACK <br />2�' <br />SIDE SETBACK <br />454, <br />PLAN CN CK NUMBER <br />r�3,e <br />FEE <br />:? 'Cz S C <br />RECEIPT NO. <br />USEZONE <br />LOT AREA <br />VACANT SITE <br />❑ YES ❑ NO <br />E <br />VALUATION <br />FEE <br />BUILDING <br />$q5 7 O <br />_ <br />- <br />TYPEOFCONST. <br />ALLOWA /ACTUAL <br />OCCU ANCY GROUP <br />NO OF DWELLING UNITS <br />2 <br />PLUMBING <br />^ <br />l <br />— <br />SIZE OF BLDG <br />Z160 sF7' <br />SF GAR. <br />NO. OF STORIES <br />2 <br />8SMT, <br />D Y <br />WN <br />OCC LOAD <br />1114 <br />MECHANICAL <br />OTHER <br />FIRE SPRINKLERS P.EOUTAED ❑YES pN0 <br />HEIGHT LIMITATION <br />��jj5� I <br />�'Cl <br />STATE BUILDING SURCHARGE <br />L <br />r <br />APPLICATION ACC BY PLANS APPR. BY <br />G/! <br />STATE ENERGY SURCHARGE <br />PUBLIC WORKS <br />/ <br />TOTAL <br />