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APPLICATIC ] FOR CONSTRUCT'-)N PE�MIT � <br /> TO BE COMPLETED IN BLACK INK—PLEA5E PRINT � <br /> BUILDING DEPARTMENT HEATING SYSTEM: ❑GAS ❑ELECTRIC ❑ _� <br /> 259-8810 <br /> DEMOLITION ❑ COMBINATION ❑ BUILDING ❑MECHANICAL ❑PLUMBING ❑ SIGN <br /> � ONTlER M�R ADORE55 GiTY ZIP PMONE <br /> E���1 1c,2ra.t /��z I?�v�K�..ti i�r'.�..6+'� 3e'e'- �ir <br /> TEWWT MAILMDNESS ��T�' =�P P�E <br /> C'i4/1�T��5 I)Fitf t dF_i.S�:TS �Sa�/ /l✓c,r��t f.✓�s+r.cr% 776 j�'jo <br /> APCMITECTORDESIGNER M�ILADDRESS CIT1 ZIP PHONE <br /> GEN� CONTRAGTOR M�RIDDAE55 GITY ZIP PHONE STATELICENSE� <br /> AIECHMIICAI.CONTRACTO� ODRE55 CITY ZIP PMONE STATELICENSEt <br /> PLUMBM(3CONTRALTOR MAILADDOE55 CITY 21P PMONE STRTEUCEN5E1 <br /> CONTR�CT PRIGE OF WORK <br /> OESCR9E NNNI(AND SOU�RE FOOTAGE INVOIVED CONTACT PEfiSON AND PHONE NO. <br /> I HEREBY CERTIFV THAT I HAVE READ AND EXAMINED TIiIS <br /> PROPOSED USE OF BUILDIN6 APPLICA'ION AND KNOW THE SAME TO BE TRUE AND CORRECT.ALL <br /> PROVISIONS OF LAWS AND URDINANCES GOVERNING THIS TYPE OF <br /> I.EGAlOESCRIPTIONOFPPOVEHTV�SNOWNOEtOWORATTACNTWOCOPIES� WORK WILL BE COMPLETED WITH WHETHER SPECIFIED HEREIN OR <br /> NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO G!'eE <br /> �or e�acK � qUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS �F �NV <br /> Oy �,✓L/Lf�R- F OTHER STA?E OR LOCAL LAW REGULATING G'NSTRUCTICiJ OR THE <br /> PERFORMANCE OF CONSTRUCTION.THAT I AM AUTHOCiIZED BY THE <br /> `/y�/�,� W A OWNER OF THIS PROPERTV TO PERFORM THE WURK FOR WHICH <br /> APPLICATION IS MA AND I COMPLV 4�'ITH THE STATE <br /> P�RCELTAX I.D.NUMBER CONTRACTORS LAyJ 1 7 R AND 296200 N;AC. <br /> CONSTIiIILTIONLO�NLENDEH.A�DRESS.TELEPMONENUMBER � _.�� � <br /> s� 93 <br /> Ecr�oDn s'�""=�'E L/ � 2 iSTi�►r�d e D�iE <br /> � f11y �j(�[�K�r �/�. ,'� CiIYBUSME IiCENSENO <br /> J` <br /> p�� MECHIINICAI <br /> ►q. IYPE Of FlXTURE OR ITEM FEE NO. TYPE OF EOUIPMENT �E <br /> WATERCL�SET(TOILET) —�— Al�A/HNDLGUNITS—H.P. � <br /> BATHTUB ; FORCED AIR SYSTFM.,—B.T.U. M E.A. ' <br /> UVATORY(WASH BASIN) � UNIT HEATERS—B.T.U. M � <br /> SHOWER � CLOTHES DRVERS ' <br /> KITCHEN SINK 6 DISP � ; VENTILATION FAN � <br /> � DISHWASHER � RANGE H000 ' <br /> LAUN[`qY TflAY ; VJATER HEATER ` <br /> � <br /> CLOTHES WASHER W000 STOVE <br /> ' URINAL ' ME'AL FIREPLACE(WOOD BURNING) ; <br /> '� DRINKING FOUNTAIN FIREPLACE INSE9T � <br /> � FLOOR ORAIN � HEAT PL'.MP _ ' <br /> � BACKFLOW PREVENTERS GAS PIF'ING __� <br /> � ROOF DRAINS—RAINLEADERS � EXHAUST FAN ' <br /> � SINK(SERVICE—$AR,ETC.) <br /> �T <br /> 1 <br /> 1 <br /> I <br /> 1 <br /> SUB�fOTAL $ SUB TOTAL $ ' <br /> PERMIT $ PERMIT $ � <br /> TOTALFEE $ ' TOTALFEE $ ' <br /> FOR OFFlCE USE ONLY: <br /> � FRONiSETB�GK RERRSETB�GK SIDESETBACK PUNC�MI:Q%�MBEP� FEE RECEIPTNO. <br /> 1 � <br /> osezorie LOT�RER WGRNi51TE FEES VALl1pT10N �E <br /> ❑ YES ❑ NO �UILCING �' D� <br /> TVPfOfCON57. NO.OFSTORIES oCCuverMv Hodo'NFuwGuvrtS - ' <br /> 'D <br /> �^W° r�urasiNc � <br /> - � <br /> SIZEOFBLDI:. FIRESPflINKLER5RE0'D BASEMENT ME:HANICAL � <br /> ❑ YES ❑ NO — <br /> OCCUPANCY LOAD FIRE AURM REOD MEIGHi LIMITATION AGUITIONAL PLAN CHECK � <br /> i <br /> CTNEF � <br /> FE�SON ' <br /> •>TATE BUILDING SURGHARGE � � � <br /> i <br /> MTAKEBY PUNSAP?ROVEDBv CITYOFEVEREiT PUBLICWORKS � <br /> LOCAL SALES a� � <br /> o�.E TAX CODE IS 3105 Tou� ; <br />