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iPPLICATION FO'� <br />the Evergreen CONSTRUCTION <br />everett PERMIT <br />BUILDING DEPARTMENT <br />259-8810 TO BE COMPLETED IN INK - PLEASE PRINT <br />❑ DEMOLITION ❑ COMBINATION ❑ BUILDING ❑ MECHANICAL <br />O PLUMBING <br />/// /t�< <-�� a�dM.sC 9s�je Shy- 6SJy <br />ARCHQFCT OR D L.ILNED MAIL ADDRL35 Gry ZIP PHONE <br />reYe.eN <br />❑ SIGN <br />GENERAL CONTRACTOR MAID AJORESS CITY I'll PHONE LICENSE <br />MECHANICAL CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE <br />PLUM^BINGCO/VIRACIOR < MNL ADDRE55 (( CITY TIP PHONE IICCN$C• <br />Al /c �� u5/mac /yZ t�vL !J ]s�o� SRZJII 56� %a;J RTSPj�q/cf <br />l NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPLANSERT ❑ BUILDING RELOCATION <br />VALUATION ^F N'ORK rCOST OF MATERIAL5 PLU5 LAGORI <br />DESCRIBE WO K ( <br />l <br />USE OF BUILDING <br />C:,rv1Me. <br />LEGAL DESCRIPTION OF PROPERTY <br />V2 os (Lt.k 144 14U,r <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP- <br />PLICATION AND KNOW THE SAME TO RE TRUE AND CORRECT. ALL <br />PROVISIONS OF LAWSAND ORDINANI,ES GOVERNING THIS TYPE <br />CF WORK WILL BE COMPLETED WITH'NHETHER SPECIFIED HERE- <br />IN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO <br />GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF <br />ANY OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION <br />OR THE PERFORMANCE OF CONSTRUCTION. <br />SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT DATE <br />PROJECT ADDRESS <br />APPLIC.ANT.SCRYBUSINESS LICENSE NO <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />NO. <br />TYPE OF EQUIPMENT <br />FEE <br />WATER CLOSET (TOILET) <br />cz— <br />— <br />A/C—A/HNDLG UNITS — H P. <br />BATHTUB <br />REFRIGERATION UNITS — H P. EA. <br />LAVATORY I WASH BASIN) <br />BOILERS — B.T U /H P. <br />SHOWER <br />GAS FIRED A C. UNITS — B.T.0 <br />KITCHEN SINK A DISP <br />FORCED AIR SYSTEMS — R T U. M EA. <br />OISI(WASHER <br />WALL HEATERS T. U. M <br />LAUNDRY TRAY <br />UNIT HEATERS—B.T.U. M <br />CLOTHES WASHER <br />EVAPORATIVE COOLERS <br />URINAL <br />CLOTHES DRYERS <br />DRINKING FOUNTAIN <br />VENTILATION FAN <br />FLOOR DRAIN <br />RANGE HOOD <br />_ <br />BACKFLOW PREVENTERS <br />WATER HEATER <br />ROOF DRAINS — RAINLEADERS <br />WOOD STOVE <br />SINK (SERVICE — BAR. ETC) <br />METAL FIREPLACE 6 CHIMNEY <br />FIREPLACE INSERT <br />HEAT PUMP <br />GAS PIPING <br />EXHAUSTFAN <br />SUBTOTAL <br />S <br />— <br />SUBTOTAL <br />PERMIT <br />$ <br />PERMIT <br />TOTALFEE <br />S <br />TOTAL FEE <br />PLAN CHECK NUMBER <br />FEE <br />RECEIPT NO. <br />I PONT BE III ACK <br />REARSEIBACK <br />SIDE SETBACK <br />USE ZONE <br />LOT APEA <br />VACANT SITE <br />OYES ONO <br />FEES <br />VALUATION <br />FEE <br />BUILDING <br />$ <br />TYPE OF CONCH <br />OCCUPANCY GROUP <br />NO OF DWELLING UNITS <br />_ <br />PLUMBING <br />512E OF BLDG <br />NO OF STURIES <br />MAX OCC LOAD <br />MECHANICAL <br />OT14ER <br />FIRE SPRINKLERS REQUIRED ❑ YES O NO <br />STATE BUILDING SURCNMGE <br />STATE ENERGY SURCHARGE <br />APPLICAIIONACC BY <br />PLANS CHECKER BY <br />APPR FOR ISSUANCE BY <br />PUBLIC WORKS <br />TOTAL <br />— <br />VHUetHI Y UWNtH3 RHt HtZ,rUP OIVLM FUH ..IcnmmuTv HLL <br />I PROPERTY LINE LOCATION,, AND RELATED EASEMENTS. <br />1 <br />i <br />