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OF APPLICATION FO.�' eYereB <br />cm Lett CONSTRUCTION <br />ev e PERMIT <br />TO BE COMPLETED IN BLACK INK— PLEASE PRINT <br />BUILDING DEPT. <br />259-874{5f�� ❑ /COMBINATION ❑ BUILDING ❑ MECHANICAL ❑ PLUMBING ❑ SIGN <br />OWNELO (IN`' CL G^SL kLADOP-C `'�C PHONE <br />ZIP PHONE <br />GENERAL CONTRAC TOR MAIL ADDRFSS CITY ZIP PHONE LICENSE• <br /><7"a-,- At1.4,.- VT451'II /Vi "` '�/.,35— --1z7,r-51,4eOlk <br />PLUMBING CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE• <br />CLASS OF WORK <br />Jar NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRF L. INSERT ❑ BUILDING RELOCATION <br />DESCNIRF wuNK /� <br />IA/CTAO// i✓.v.i 1Fl.ril-A,4 TIA.; e'i.LJ/JPe l�z!C/.�i%A✓� /C <br />UBE OF BOIL INO <br />M r'6LF fA1,17C17F• <br />LHE IEBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP• <br />ICATION AND KNOWTHE SAME TO BE TRUEANDCORRECT. ALL <br />PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE <br />OF WORK WILL BE COMPLET"ED WITH WHETHER 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 7—AO J: <br />1 w <br />X —Y <br />LEGAL DESCRIPTION OF PROPERTY (SHOWN BELOW OR AITACN LOUR COPIEB) <br />'],tiy H ��tJ�F <br />LOT­-7 BLOC or - <br />PROJECT ADDRESS <br />NO <br />APPLICANr5CITYBUSINES4w; <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTURE <br />FEE <br />NO. <br />TYPE OF EQUIPMENT <br />FEE <br />WATER CLOSET (TOILER <br />_ <br />AIR COND. UNITS—H.P. EA. _ <br />BATHTUB <br />REFRIGERATION UNITS—H.P. EA. <br />LAVATORY (WASH. BASIN) <br />BOILERS—H.R EA. <br />SHOWER <br />GAS FIRED AC. UNITS —TONNAGE EA. <br />KITCHEN SINK DISP. <br />FORCED AIR SYSTFMS—B.T.LL M EA. <br />DISHWASHER <br />_ <br />WALL HEATERS-8. T.U. M <br />LAUNDRYTRAY <br />UNIT HEATERS—B.T.U. M <br />CLOTHES WASHER <br />EVAPORATIVE COOLERS <br />WATER HEATER <br />CLOTHES DRYERS <br />URINAL <br />VENTILATION FAN <br />DRINKING FOUNTAIN <br />RANGE HOOD _ <br />FLOOR DRAIN <br />AIR HANDLING UNIT— C.F.M. <br />_ <br />VACUUM BREAKERS <br />_ <br />ROOF DRAINS—RAINLEADERS <br />_STOVE <br />METAL FIREPLACE A CHIMNEY <br />_ <br />_ <br />SINK SERVICE —BAR, ETC. <br />WOODSTOVE/FIREPLACE INSERT <br />SUBTOTAL <br />SUBTOTAL IT <br />PERMIT f <br />PERMIT 11 <br />TOTALFEE f <br />TOTAL FEE B <br />THIS PORTION TO BE COMPLETED BY BUILDING DEPT. PERSONNEL <br />FRONT SETBACK <br />REAR SETBACK <br />WA• <br />SIUE SETBACK <br />PLAN CHECK NUMBER <br />S S / l c, / / (0 <br />PLAN CHECK FEE <br />FEE L{ r RECEIPT NO 7 �� <br />USE ZON <br />�� <br />LOT anf.4.. w <br />N /J <br />VACANT SITE <br />OYES MNO <br />f <br />FEES <br />VALUATION <br />FEE �I <br />_ <br />TYPE Of Cfu15i <br />OCcurnucr cnouP <br />NO OF DwF.Lt UNITS <br />X-N I R-3 <br />SIZE OF BLDG NO OF STORIES MAX OCC LOAVI <br />if/A. / � MO." F1 1 NA, <br />BY <br />m/w <br />BY <br />./,er- <br />APPR FOR ISSUANCE BY <br />L - Cl . <br />BUILDING <br />PLUMBING <br />MECHANICAL <br />OMER <br />PENALTY <br />TOTAL <br />