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I:�T7w. <br />k_PLICATION FOI ` I <br />Inr EYsrprwn <br />Cltt OF <br />CONSTRUCTION <br />everett <br />PERMIT <br />e <br />BUILDING DEPARTMENT <br />259.8810 <br />TO BE COMPLETED IN INK- PLEASE PRINT <br />❑ DEMOLITION ❑ COMBINATION ❑ BUILDING <br />3 MECHANICAL <br />❑ PLUMBING <br />® SIGN <br />OWNER <br />MAILADDRESS Cltt ZIP <br />PHONE <br />rzFcTT <br />f✓IPU� I�{pZ ��/Ee`rr "ttA <br />-17-1-1`11 <br />Wny <br />3 <br />ARCHITECT OR DESIGNER <br />MAIL ADDRESS Cm ZIP <br />PHONE <br />GFi11GRAE CONTRACTOR <br />SIK1-1 <br />lAAIL ADDRESS CITY ZIP <br />PUONE <br />LICENSE <br />�` / <br />4�e <br />n(O en aeDo0 <br />61;L a4z <br />aL,tic <br />MECHANICAL CONTRACTOR <br />MAIL ADDRESS CITY ZIP <br />PIIOM1E <br />LICENSE <br />PLUMBING CONTRACTOR <br />MAIL ADDRESS CRY ZIP <br />PHONE <br />— <br />LICENSE <br />CLA, OF WORK <br />NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPL.INSERT <br />❑ BUILDING RELOCATION <br />VALUATION OF WORK 1 OBT OF MATERIAL^ PLUS LABOR) <br />- <br />ISOoc�= <br />DESCRIBE WORK <br />(" <br />A_IC t .Ic., <br />USE OF BUILDING <br />lJ,J IJ P I C F1 {�.L <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP- <br />PLICATIONANDKNOWTHESAMETOBETRUE AND CORRECT. ALL <br />PROVISIONS OF LAWSAND ORDINANCES GOVERNING THIS TYPE <br />OF WORK WILL BE COMPLETED WITH WHETHER SPECIFIED HERE- <br />IN IN OR NOT. THE GRANTING OFA PERMITDOES NOTPRESUME TO <br />GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF <br />ANY OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION <br />OR THE PERFORMANCE OF CONSTRUCTION. <br />SIGNATO E F CONTRACTOR OR AUTHORIZED AQENT DATE,�f///� �y1'(X� <br />�l z_UV <br />LEGAL DESCRIPTION OF PROPERTY ISHOWN BELOW OR ATTACH FOURCOPIESI <br />PROJECT ADDRESS <br />_ N 0.�- r-- -164 6 <br />c � <br />APPLICANTS CITY BUSINESS LICENSE NO <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />NO. <br />TYPE OF EQUIPMENT <br />FEE <br />WATER CLOSET (TOILET) <br />A/C — A/HNOLG UNITS — H.P. <br />T— <br />BATHTUB <br />REFRIGERATION UNITS — N.P. EA. <br />LAVATORY (WASH BASIN) <br />BOILERS — B.T.U./H P. <br />SHOWER <br />GAS FIRED A.C. UNITS — B.T.U. <br />KITCHEN SINK fl DISP. <br />FORCED AIR SYSTEMS — B.T.U. M EA. <br />DISHWASHER <br />WALL HEATERS —B.TU. M <br />LAUNDRY TRAY <br />UNIT HEATERS—B.T.U. M <br />CLOTHES WASHER <br />EVAPORATIVE COOLERS <br />URINAL <br />CLOTHES DRYERS <br />DRINKING FOUNTAIN <br />VENTILATION FAN <br />FLOOR DRAIN <br />RANGE HOOD <br />BACKFLOW PREVENTERS <br />WATER HEATER <br />ROOF DRAINS — RAINLEADERS <br />WOOD STOVE <br />SINK (SERVICE —BAR, ETC.; <br />METAL FIREPLACE fl CHIMNEY <br />FIREPLACE INSERT <br />_ <br />HEATPUMP <br />GAS PIPING <br />EXHAUSTFAN <br />SUBTOTAL <br />f <br />SUBTOTAL <br />PERMIT <br />f <br />PERMIT <br />TOTAL FEE <br />sl <br />TOTAL FEE <br />l RONT SE TBAOK <br />REAR SETBACK <br />SIDE SETBACK <br />PLAN CHECK NUMBER <br />FEE <br />RECEIPT NO, <br />USEZONE <br />C _ <br />LOTAREA <br />VACANT SITE <br />OYES ONO <br />FEES <br />VALUATION <br />FEE <br />BUILDING <br />$ <br />TYPE OF CONST. <br />OCCUPANCY GROUP <br />NO. OF DWELLING UNITS <br />PLUMBING <br />SIZE OF BLDG <br />NO OF STORIES <br />MAX. OCC LOAD <br />MECHANICAL <br />FIRE SPRINKLERS REOUIRED ❑ YES ❑ NO <br />OTHER <br />STATE BUILDING SURCHARGE <br />STATE ENERGY SURCHARGE <br />APPLICATION ACC BY <br />PLANS CHECKED BY <br />n � <br />,JILaC_,T/ <br />APPR. FOR ISSUANCE BY <br />PUBLICINoRKs <br />TOTAL <br />PROPERTY OWNERS ARE RESPONSIBLE FOR DETERMINING ALL <br />PROPERTY LINE LOCATIONS AND RELATED EASEMENTS. <br />