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• 'M <br />PERMIT APPLICATION <br />COMBINATION • BUILDING • MECHANICAL • PLUMBING <br />OWNER -' MAIL AUUHUIiS <br />�! \�� �'����" (/C�'�Ic'7 /C:��i <br />ZIP PHONE <br />CSC.-L`'TD ��'. - �'-1 -' /� ;•:� <br />AR HITECT UH DE51(iNE MAIL ADD N E55 <br />PHONE LICENSE NO <br />6EHGRAL CONTRACTOR MAIL ADDRESS <br />PHONE LICENSE NO. <br />PA <br />MECHANICAL CONTRACTOR MAIL ADDRESS <br />PHONE LICENSE NO. <br />0- cz/YLCJ- - <br />PLUMBING CJNTRACTOR MAIL ADDRESS <br />7 • <br />PHONE LICENSE NO. <br />PT <br />ERMI <br />CLASS OF WORK <br />❑COMBINATION <br />m4U1LDING ❑ PLUMBING ❑ MECHANICAL <br />❑NEW <br />❑ADD) TIUN ❑gLTE11A TIfIN ❑{IC 1'nlli <br />VALUATION OF WORK <br />- -- <br />I i-'!i-VOc/ VL) <br />❑DEMOLISH <br />❑FENCE ❑WM SIGN ❑SIMIN<i POOL. <br />f <br />DESCRIBE WORK <br />_ <br />PROPOSED US <br />i� <br />OTHER PERMITS OR APPROVALS <br />Lf C <br />Tl REZONE tj SPECIAL USE <br />LEGAL DESCRIPTION OF PROPERTY [SHOW BELOW OR ATTACH <br />FOUR COPIES) <br />•VARIANCE Ji }y SN.ORLINE <br />LOT BLOCK—OF- <br />5 EPA CHECK LIST REQUIRED <br />°ENE <br />= YES <br />3ZI NO <br />JOB ADDRESS <br />MECHANICAL <br />NIuL-1C..'TIQ 00 <br />PLUMBING <br />TYPE <br />OF ENERGY <br />L]1: AS ❑ELEC. <br />TYPE OF EQUIPMENT• <br />NO. <br />1 <br />_ _ <br />AIR CONO. UNITS-M.P. EA. -IS I <br />REF RIGERgTION UNITS 1� P. En __ _7 <br />-_-._i— <br />BOILERS Nv EA. 1 <br />FORCED AIR SYSTEMS H.T.U. MEA. —�_T- <br />--"--•-- -- _.�_ L <br />- ----" ------ --- ^-T— <br />SPACE & WALL HEATERS - H.T.U. I - <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />— <br />-- <br />HAIH TUBS <br />S <br />CLOTHES WASHER <br />DISH WASHE[IS <br />,1 <br />DRINIIIN(i FOUNTAINS <br />I <br />FLOOR DRAINS <br />I <br />KITCHEN SINKS & DISP. <br />ry I <br />UNIT HEATERS H.T.V. <br />EVAPORATIVE C_OOLE_H_SROOF <br />CLOTHES DRYERS <br />BAR SINKS <br />I <br />/ <br />I %{Io i) <br />DRAINS RAIN LEADERS <br />SHOWER BATHS <br />_ <br />VENTILATION FAN <br />SERVICE SINKS <br />RANGE HOOD I 21d� <br />SUMPS - SEWAGE PUMP <br />-L -- •- I--r <br />AIR HANDLING UNIT C.F.M. <br />URINALS I <br />WATER CLOSETS <br />-._'— '- -T <br />WATER HF.ATE HS -ELECTRIC �' I J <br />WATER NEATER <br />..._ _. _..._._..L--- <br />WASH BASINS <br />LAUNDRY TRAYS <br />FAC. BUILT FIREPLACE & CHIMNEY I <br />_ _ GAS. SYSTEM: NO OP OUTLE.15 <br />SUB TO to S (J <br />I <br />_---_. _._•- PERMIT .-S <br />.. <br />SUB TOTAL <br />TOTAL. FEE S <br />- - - - - - - -- <br />PERMIT S �� <br />THIS YF.RMIT E. WORK O <br />ES NUI 1. AND VOID II WUHK OR C(INSTRUC <br />-- <br />TQTAL FEE - <br />TION AUTHORIZED IS NOT C(IMMLNC(0 WITHIN 120 DAYS. OR IF <br />)ZED <br />CONSTRUCTION OR WORK IS SUSPENDED O{I ABANDONED FOR A <br />WATER SERVICE SIZE BLDG. SUPPLY SIZE S ij <br />PERIOD OF 120 DAYS AT ANY TIME AFTER WORK II: COMMENCED. <br />•SETN HEAR YARUS TBACKI TIE FIERY CERTIFY THAT I IIAVC I4LAD AND EXARUNID THIS AP- <br />PLICATION AND KNOW THE SAME TO RE TRUE AND CORRECT. ALL <br />PROVISION OF LAWS AND ORDINANCES GOVERNING TI/IS TYPE <br />F I V �� <br />3 <br />OF WORK ILL BE COMPLIED WITH WHET /EFl SPEC' FILU HEREIN <br />USE ZUNE LUT AHLA VACANT SITE <br />OR NOT. T IF GRANTING OF A PER IT OES NOT PRESVME TO <br />�/- <br />OYES ONO <br />GIVE AUTII PITY TO VIOLATE OR AN L THE PROVISIONS OF <br />ANY OTHE STATE OR LOMWIN(i CONSTRUCTION <br />TYPE OF CONST. OCCUPANCY GROUP NO. OF DWELLING <br />UNITS <br />OR T E E OR MA NCE OF1 <br />SIZE OF BLDG. NO. OF STORIES MAX. OCC. LOAD <br />_ _SIGNA TE <br />-1 INk Ll)IVt �- IIASF MLIJT FINk S'1'NINKl111.5 <br />UH CONT TD <br />1 RE❑OVEREU �O <br />lV <br />LAN HECK NUMHEH PLAN CIILCK EL <br />FEE 'RECEIPT NO. <br />SPECIAL CONDITIONS: <br />1J SQ 7 <br />- - <br />-FEES VALUATION FEE/ <br />BUILDING S�-li G�'..J cl-.. <br />SEPA REVIEW COMPLETE: DYES ElPL <br />NO <br />UMRINR <br />c0nIOcI PIORRIDQ dept. <br />MECHANICAL <br />OTHER 1 <br />IIMlIW1t KIN ALUIIIU YY' IPU`145c"ttKI NY NY <br />1 <br />PENALTY SEC. 003 Id <br />TOTAL <br />