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rnsewr0�� /���PLICATION FOEt everetl <br />°�TM°F CONSTRUCTION <br />�verett PERMIT e <br />TC BE COMPLETED IN BLACK INK— PLEASE PRINT <br />BUILDING DEPT. <br />259•8745 ❑ COMBINATION � BUILDING ❑ MECHANICAL ❑ PLUMBING ❑ SIGN <br />�...�, �irvrni.vnir ��nvri,� i-,v�.�ll�'-r✓/-�V-C /"is5-�U `�t�� �Y/"/y/L/ <br />�NGMITECTORDESIGNER MqI�ADORESS Citt 21P PnONE � <br />G/EN[RRLCONTR/AG�TORr MRILApOFESS piV 21P PMONE LILENSE• <br />f{�is.4Y- F`Arl+•ns i//1-'19y�✓f, SV h:r..,� %� (JLa7//S-' '�%C-i//7 L/�i �/1P• G�'.�J(�L�i <br />MECHANIGLCONTRNCTOIY MAILq�ORE55 ' CiiV ZIP PHONE I L�CENSE• <br />PWMOINGCONTRRCiOR MNILAD�PESS CITY ZIP PMONE �ICENSE• <br />❑ NEW ❑ ADDITION ❑ ALTERATION QI REPAIR ❑ DF.MOLITION ❑ WOODSTOVE/FFPL.INSERT ❑ BUILDING RElOCA710N <br />VALURiION OF 1YoORN �COSi OF MATCRIALS P W 5 LABORI <br />CJ �/ �. / 2 <br />UESCNIBE WORK <br />usE <br />L[GPL DESCRIPiION OF PqOPERTY�SNOWN BELOW OI <br />� 7 �_/� Od <br />l0 �a2BLOC O ' __ <br />A�c yi»,�-�/l[�_pa G- <br />�qOJEGTADJRE55 <br />ys'07- .P, , <br />» US[ ZONE <br />I HEREBY CERTIFY THAT' �iAVE READ AND EXAMINED TFIIS AP- <br />PLICATION AND KNOW TF c SAME TO BE TRUEAND CORRECT. ALL <br />coaies� pROVISIONSOFLAWSANDORDINANCESGOVERNINGTHISTYPE <br />OF WORK WILL BE COMPLETED WITH WHETHER SPECIFIED HERE- <br />IN OR NOT. THE GRANTING OFA PERMIT DOES NOT PRESUME TO <br />GIVF AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF <br />AN\'OTHER STATE OA LOCAL LAW REGULATING CONSTRUCTION <br />OR THE PERFORMANCE OF CONSTRUCTION. <br />FiGNATURE OF CO4iRRCiOR OF 4UiHORI E AG[NT DATE <br />X ��/�i/�//��� ,r-; �--F/ <br />APPIIGeNTS dIV BUSINE55LICENSE NO. <br />TYPE <br />AIRCOND. UWITS— <br />RCFRIGERATION U <br />BOILEFS—H.R EA. <br />GAS FIR[D A.0 UN <br />FORCED AIR SVST! <br />1VALL HEATERS—[1 <br />rcn�ni� S f£RMIT S� <br />TOTALFEE 5 70TALFEE SI <br />THIS �'ORTION TO BE COMPLETED BY BUILDING DEPT. PERSONNEL <br />REFNSEtBRCN SIOES[LBRCK P�qNCNECNNUMPEB PLANCNECNFEE <br />fC[ RECOPi NO <br />LOiRREA V�GNi51i[ <br />OVES ONO FE[5 V�LURTION FEE <br />APpIICAiIONACC BI <br />OCCIJPAIICV GROUP <br />n <br />APPR fON <br />UNITS <br />BUILDING <br />PLUMBING <br />MECHANICFL <br />OTHER <br />PENALTY <br />TOTAL <br />SGS 95! <br />Ca�sd <br />2 <br />O <br />--1 <br />c� <br />m <br />� � <br />..� <br />N 2 <br />m <br />�o <br />m o <br />� <br />o� <br />m <br />-i z <br />s -a <br />m <br />.O Z <br />C <br />D —i <br />rx <br />�. <br />� L� <br />< <br />T <br />C� .'O <br />-*i a <br />-i m <br />`m� <br />N <br />O <br />cr <br />c� m <br />C N <br />� N <br />m <br />z c� <br />�r <br />• m <br />2� <br />� <br />� <br />S <br />T <br />2 <br />1 <br />2 <br />N <br />Z <br />O <br />�-i <br />C] <br />m <br />