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APPLICA(IONPFORVCIT NSTRLuTION <br />Ins Evergreen <br />CITY OF <br />everett <br />BUILDING DEPARTMENT 259.8810 TO BE COMPLETED IN INK— PLEASE PRINT <br />CITY ZIP PNONZ <br />}(' '`o-1EM'1M{�L AVURE/55• I} IlI <br />OWNER <br />ZIP PHONE <br />_�`-Llal' GUEfE_1�� �Q1�Fl <br />MAR ADDRESS GIl Y <br />TENANT <br />_ PHONE <br />CM LADDRE55 GItY ZIP <br />ARCHITECT OR DESIGNER �.2 I •'1 <br />/I <br />A 1 / 1 1... �_I,.�i IZ��n )-A/.1ll�lfbl LICENSE <br />Qla?v>' CITY ZIP PHONE LICENSE• <br />MECHANIC LCONTRACTOR LADDRE55 <br />LICENSE <br />PLUMBING CONTRACTOR MAIL ADDRESS <br />CHY ZIP PHONE <br />w A- <br />FL-ABS OF WORK <br />❑ NEW ❑ ADDITION .9 ALTERATION ❑ REPAIR ❑ DEMOLITION r^❑APWOODSSNOVEJFRPL NONONE INSERT ❑ BUILDINGRELOCATION <br />NO <br />WORK <br />LOT BLOCK OF <br />I HEREBY CERTIFY THAT 1 HAVE READ AND EXAMINED THIS APPLICATION AND <br />KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS AND <br />ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLETED WITH <br />WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OFA PERMIT DOES NOT <br />PRESU'4E TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF <br />ANY OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION OR THE PER <br />FORMANCE OF CONSTRUCTION, THAT I AM AUTHORIZED BY THE OWNER OF <br />THIS AND I OPERTY COMPLYTW WITHFRM THE THE STATE CCRK FOR ONTRACTIORSHLAWL152TIN IS MADE <br />70RCW AND <br />296,200 WAG. tie <br />SIGNATURE OF CONI RACIUn OR AUIIIORIZEEDDAGENT <br />SO DATE•'" 6S'�SooB <br />l k ���� -� <br />Al LI ANTS CITY SINESS LICE E NOAND BUSINESS NAME <br />MECHANICAL <br />PLUMBING <br />FEE <br />NO. TYPE OF EOUIPN <br />VO. TYPE OF FIXTURE OR ITEM <br />A/C - A/HNDLG UNITS - M.P. <br />WATER CLOSET (TOILET) <br />FORCED AIR SYSTEMS- BT.I <br />BATHTUB <br />UNIT HEATERS -BT.U. M <br />LAVATORY (WASH BASIN) <br />_ <br />CLOTHES DRYERS <br />SHOWER <br />VENTILATION FAN <br />KITCHEN SINK & DISP. <br />RANGE HOOD <br />DISHWASHER <br />— <br />— <br />WATERNEATER <br />LAUNDRY TRAY _ _ <br />WOODSTOVE <br />CLOTHES WASHER <br />_ <br />- <br />METAL FIP.EPLACE 6 CNIMNE <br />DRAINS - <br />RFRVICF- <br />27-1U <br />SUB TOTAL <br />PERMIT <br />TOTAL FEE <br />❑ YES <br />-lz_ <br />0 <br />HEAT <br />FAN <br />SUBTO <br />S <br />— <br />PERMIT <br />E <br />— <br />_ <br />TOTAL <br />9 <br />SIDESETBACK <br />PLAN CHE <br />KNUMBER <br />FEE I <br />PACANT IT <br />FEES <br />V� <br />❑ YES NO <br />BUILDING <br />4 r <br />NO.OF DWELLING UNITS <br />- <br />-$- <br />PLUMBING <br />_ <br />DCc. LOAD <br />;3 <br />MECHANICAL <br />- <br />NEIGITTLIMITAt1ON <br />OTHER <br />STATE BUILDING SURCHARGE <br />STATE ENERGY SURCHARGE <br />PUBLIC WORKS <br />TOTAL <br />EA <br />L �i1 I��al <br />FEE <br />