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pppLlCta f ION pFERR�C'T NSTRIia.T10N <br /> ,.,,,«.�� <br /> m�e�e,v,e�^ � <br /> C�TV OF <br /> everett <br /> BUi�DING DEPARTMENT TO BE COMPLETED IN INK- PLEASE PRINT <br /> 259-BB10 <br /> rwra.n rnei�nooaEss <br /> cnv zi� �•�o•,e <br /> " EVERETT 98r201 . 25"L-0087 _.__ <br /> VIRGINIIi GROSSMAN 630 RCCKER AVE___ __- �—r� - ProNe <br /> MniL nDD�E55 <br /> tE11ANL _ _ <br /> �ii�— Z�p PMONF <br /> qq�qilELTOA�E9GNER MAiLA0DAE55 <br /> M�IL�UDFE55 GIIY <br /> I�P MONE LiCINSC• <br /> 4CNERµCONiPFCtOR � <br /> AILCNFNICOLGOHiRiC10R 1A�1 AODRf55 <br /> --- cir. zm ���oHe AR�,'��`��,�`1 4 1 LL <br /> RELTAIILE SHEET MLTAL/DBA � .� .nnwood-98�J3bo�7-D=125��,-- <br /> x t" '�1 I�AC�INST1lLL7iTS�NS.�--I.TA>oo��s-�`�9fith-S�t..-SW c����-. Y <br /> C+] ly�1 Pwr.ramoccv»<t�oe <br /> Q�b y y c.�ssovwoarc n <br /> C'� � ❑ NEW ❑ ADDITION W ALTERAiION ❑ REPAI(i ❑ OEMOLITION wO^cWO00�5NOND/PHo E oSERT ❑ BUILOINGC�ELOCATION <br /> y�i 1„' 1CNnNi IMFROVEMEHi ON IMCPIOP REMODEL ONLV <br /> r.orvtn�cTveiceovwoen $125.�0 <br /> 0� 0 p[SLPiBEWOPK IOSOV�AE�OO1AGEiNVOIVE� — <br /> �y H Install 25 ft gas i in for Coc:cto -- -- <br /> H x� enoPosEo u5[0�Bui�oieG I HEAEBY CERTIFV THAT I MAVE REAO AND EXAMINED TMIS APPUCAiION AND <br /> T KIJOW'HE SAMF TO BE TRUE ANO CORPECT ALL PROVISIONS OF LAWS AND <br /> [s7 O� SFR OFDINANC[S GOV[RNING TNIS TYFE OF WORK WR�BE COMPLETED WITH <br /> �M iec.�oesceivrioNorvnoveen�sr�wme[�owona*�cHFouecov�es �y�itTNERSPEGiFlEDHEREiNORNO7.THEGRAniIi�GOFAPEPA11tDOhSNOT <br /> PPESUME 10 GNE AUTHORITY TO VIOLAIE OR CAN�[L TN[FROVISIONS OF <br /> "� QrJ �� _ qryyOTH[RSIATLORLOCALLAWREGUI.ATINGCONSTRUC110NOi7TNEPER� <br /> M Ls1 O �aT-- eL�K FORtdANC[OF CONSTRUCTION.THAT I AM AU7HOR�ZE�8�TH�OWNER OF <br /> C1• O TMISPROPERhTOPERFORMTH[WORKFORWHICHAPPUCATIONISIdADE <br /> �"� AND � COtdFLY \VITH THL STAiE CONiRACTORS LAIN 1827 RCW FND <br /> zH� <br /> � 296 2001'lAC. <br /> s�crcniur+t.ormNrnnc;�,�:..c��n�aaamtieuir onr� <br /> g�� _ A ��� � �.� i� �� �r <br /> � <br /> ��� f'ROJECI AO�AE55 Rnnl ILv�S Ptt b115ME551�. HSC Np ANO 9U9NC5$N4UE <br /> 630 Rucker Avenue, �verett <br /> y � y MELHANICAL <br /> PLUMBING FEE <br /> � __ FEE --NO.- TYPEOFEOUIPMENT — <br /> NO. TYPEOFFI%NREORITEM p,iC-q�HN�LGl1NITS-`�? <br /> WATER CLOSEi1T��LEn FORCED AIR SYSTEMS-B.T.U. M EA <br /> BATHTUB UNITHEATERS-BT.U. M __ <br /> 1 LAVATORYIWASHBASIN) — CLOTNESDRVERS -� <br /> �� SHOWEP _ VENTILATIONFAN — <br /> KITCNEN SINKBDISP. qpryGE HOOD <br /> DISNWASHER WqTER HEATER -- <br /> LAUNDRYTRAY � WOODSTOVE — <br /> , ' __ CLOTHES WASHER - METAL FlREPLACE 8 CHIMNEV _ — <br /> i �� URINAL FlREPLACLINSERT _ —_ <br /> OFINKING FOUNTAIN NEAT PUMP - <br /> FLOOR DPAIN GAS PIPING _z�_ Ft• -- <br /> BACKFLOW PREVENTERS - EXMAUSTFAN — <br /> 1 ROOF ORAINS-RAINLEADER$ -- __ <br /> � �� SINK�SERVICE-BAR.ETCJ __ <br /> � _ - — <br /> �� . <br /> __ g SUBTOTAL 5 �-—� <br /> SUBTOIAL — PERMIT 5 —��- <br /> � PERMIT $ — — TOTAL FEE 5 `3 <br /> _I�, TOTALFEE 5 PUNCMECRwIIMBEP FEE PECEIPiNO. <br /> flEPRS[iB�CK Slp[SEiBACN <br /> lPONISETBPCR �S/� �� �_ <br /> wcervisrt[ FEES VALUATION FEE <br /> USEZO4[ ��AAEA „YES G NO <br /> _ �UILDING _ ___ — <br /> *rrTorwNsr. occuveHcrceow �ooroweiu�+cuMT*S — - ---- -- <br /> auowno�Eincruc� PLUMDItJG _ ___ -- -- <br /> sreo�eioc. Noo�sroeies asur. a��io�� MECMANICAL �� �, <br /> ❑Y - - <br /> pN <br /> N[icnruMir�tioN OTHER _ -- <br /> nvE scewKtensnewiaco c re5 u No STATE BUILDING SURCHARGE _ <br /> STATEENERGYSURCNARGE _ _ .___ -_- <br /> qV(�LIGRiIONFCCBV PL�YSA�'�RBV pUBLICWORKS <br /> TOTAL <br />