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APPLICRTI� N FOR CONSTRUC"..ON PERMIT <br />CITY OF EVERETT • BUILDING DIVISION � <br />3200 CEDAR STREET • EVERETT, WA 98201 • 259-8810 <br />❑ DEMOLITION ❑ COMBINATION fl BUILDING ❑ MECHANICAL ❑ PLUMBING ❑ SIGN <br />MECHANIGLCONTR�CTOR MAILADDPE55 Cltt 21P PIIDNE STRiEIICENSE� <br />PLUMBINGCONiR�CTOR MRILMDRE55 CI7V ZIP N��ONE STATELICENSE� <br />LOT <br />PPICE O' WORK <br />AND SOU�aE FOOT�GE INVOLVEO <br />BLOCK <br />PARCEITA%I.O.NUMBER <br />CONSTRUCTION LORN LEN�ER.ADDAE55. TELEPHONE NUMBER <br />PLUMBING <br />NO. TYPE OF FIXTURE OR ITEM FEE <br />WATER CLOSET(TOILET) <br />BATHTUB <br />LAVATORY (WASH BASIN) <br />SHOWER <br />KITCHEN SINK 8 DISP <br />DISHWASHER <br />LAUNDRY TRAY <br />CLOTHES WASHER <br />URINAL <br />DRINKIN6 FOUNTAIN <br />FLOOR DRAIN <br />BACKFLOW PREVENTERS <br />SINK (SERVICE — BAR. ETC.) <br />SUBTOTAL S <br />PERMIT S <br />TOTAL FEE S <br />FOR OFFICE USE ONLY: <br />FRONT SETBr1CK AEAii SETBACK SIOE SETA�CK <br />USE ZONE <br />IICIGIITI.IMI7ATION <br />OCCUPANCY NOOi5i0NiE5 <br />GROUP q <br />/% _ � / <br />✓ — / /1R. <br />LOTFREA <br />no. or ow«uNo <br />UNIiS <br />OCCUPFNTLOAD <br />REA50�� <br />o;2D <br />REASON <br />PLA �/.PPROVEDBY <br />Ijti <br />OA1E �-J7-�� <br />HEATING SYSTEM: ❑ GAS ❑ ELECTRIC ❑ <br />CONTFCT PERSON PND PIIONE NO. <br />1 HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS <br />APPLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL <br />PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE OF <br />WORK WILL BE COMPLIED WITH WHETHER SPECIFIED HEREIN OR <br />NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO G�VE <br />AUTHORITY TO VIOLATE OR CANCEL THE PROVISION OF ANY <br />OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION OR THE <br />PERFORMANCE OF CONSTRUCTION. THAT I AM AUTHORIZED BY THE <br />OWNER OF THIS PROPERTY TO PERFORM THE WORK FOR WHICH <br />APPLICATION IS MADE AND I CO�dPLY WITH THE STATE <br />CONTRACTORS LAW 1827 RCW AND 296200 WAC. <br />x DATE <br />$IGN�TURE <br />qTV 6USINE55 UCENSE ND. <br />TVPE OF FIXTURE OR ITEM � FEE <br />— AIIiNDLG UNITS — H.P. I <br />iCEDAIR5Y5TEM5—B.T.U. M E.A. <br />UNIT HEATERS — E <br />CLOTHES DRYERS <br />VENTILATION FAN <br />RANGEHOOD <br />WATER HEATER <br />WOODSTOVE <br />METAL FIREPLACE <br />GAS FIREPLACE <br />GASRANGE <br />GAS PIPING <br />EXHAUSTFAN <br />PIAN <br />VPCANi S�TE �c�� <br />nves n no ounoinc <br />xmucn/i <br />S'L I 4 PlUMOING <br />b <br />BASEMENT � AtEC11ANICAI <br />❑YES �O <br />�O�ITIONAL PLAN GMECK <br />on�en <br />ST�TE Ol11LDING SURCMARGE <br />CITY OF EVERETT rueucwonKs <br />LOCALSALES <br />TAX CODE IS 3105 TOTAL <br />SUBTOTAL S <br />PERMIT $ <br />TOTALFEE S <br />(y / /' .� <br />F[E RECEIPTNO. <br />Jz3.zd �� <br />