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The Evergreen APPLICATION F C R evereH 1 <br />CITY OF CONSTRUCTION <br />everett PERMIT 57) <br />DEPT OF COMMUNITY DEVELOPMENT SERVICES <br />CITY HALL 259-8745 <br />EVERETT, WA 98201 COMBINATION ❑ BUILDING ❑MECHANICAL ❑PLUMBING PERMIT NO. <br />OWNIR MAIL ADDRESS CITY ZIP PHONE <br />�ulEn�c E �pD-gt,V I h-,, ( r 7- IJA g670= dca-017 <br />ARCHITECT OR D61 NER MAIL ADDRESS CITY ZIP PHONE <br />k plc OL) le I :XT-YRF 0', 0.k,P.1L <br />GENERAL CONTRACTOR MAIL ADDRESS H CITY ZIP PHONE LICENSE <br />1� <br />MECHANICAL CONTRACTOR MAR ADDRESS CITY LIP PHONE LICENSEE 1 <br />' F PIUMBING CONTRACTOR MAIL ADDRESS CHI'! ZIP PHONE LICENSEE <br />CLASS OF WORK <br />❑NEW OADDITION ❑ALTERATION ❑REPAIR ❑DEMOUI ION ❑FENCE ❑SIGN ❑GARAGE ❑BUILDING RELOCATION <br />VALUATION Of WORK <br />S k) )CO Oil <br />DESCRIBE WORK <br />nar_A nlon nrH✓ ✓nry n�,.� <br />PRovouou7 a Lh mlDwc <br />Re (At it cki <br />1 HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP - <br />PLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT ALL <br />PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE <br />OF WORK WILL BE COMPLIED WITH WHETHER SPECIFIED HEREIN <br />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 <br />X� C2 l ✓• el�olv,� 7 �'- �'- <br />LEGAL DESCRIPTION OF FROM RTY PHOWN BELOW OR ATTACH FOUR COPIES) <br />LOT _BLOCK_Of <br />JOB ADDRESS <br />6n v12 US LlhO'Jr. TP�KT 7 �J ���"� �� <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTURE <br />FEE <br />NO. <br />TYPE OF EQUIPMENT <br />FEE <br />I <br />WATER CLOSET(TOLIET) <br />AIR COND UNITS -HP EA <br />BATHTUB <br />REFRIGERATION UNITS -HP EA <br />I <br />LAVATORY (WASH BASIN) <br />NOILERS-HP EA <br />SHOWER <br />GAS FIRED AC UNITS -TONNAGE EA <br />KITCHEN SINK & OISP <br />FORCED AIR SYSTEMS -BTU M EA <br />DISWASHER <br />WALL HEATERS -BTU M <br />LAUNDRY TRAY <br />UNIT HEATERS-B T U M <br />CLOTHES WASHER <br />jz <br />00 <br />EVAPORATIVE COOLERS <br />WATER HEATER <br />CLOTHES DRYERS <br />Z <br />URINAL <br />VENTILATION FAN <br />- <br />O <br />DRINKING FOUNTAIN <br />RANGE HOOD <br />S <br />FLOOR DRAIN <br />AIR HANDLING UNIT- C F M. <br />VACUUM BREAKERS <br />STOVE <br />ROOF DRAINS -RAINLEADE ITS <br />METAL FIREPLACE f CHIMNEY <br />SINK (SERVICE -BAR, 11C ) <br />SUB TOTAL <br />SUBTOTAL If <br />dC <br />PERMIT <br />S <br />- <br />PERMIT S <br />TOTAL FEE <br />S <br />TOTAL FEE f <br />QL <br />SIDE YARD SETBACK <br />ipP� —T <br />STREET SETBACK <br />REAR YARD SETBACK <br />ZOEZ <br />PLAN CHECK NUMBER <br /><j!5:1/jOCi9R <br />PLAN <br />FEE .? <br />�— <br />CHECK FEE <br />RECEIPT O <br />USE ZONE <br />r%-�( <br />FFC--ONST <br />LOT AREA <br />VACANT SITE <br />DYES (51SD <br />FEES <br />VALUATION <br />FEE <br />TYPE OF <br />OCCUPANCY GROUP <br />Anp w K 5 <br />NO OF DWELLING UNITS <br />I1 <br />BUILDING <br />S <br />t Q <br />1 C <br />SIZE OF BLDG <br />Aj(>InJ 6ct75.rl <br />NO OF STORIES <br />1 <br />MAX OCC LOADW <br />PLUMBING <br />to <br />FIRE ZONE <br />BASEh1ENT <br />-� <br />Bk UROOMS <br />-- <br />FIRE SPRINKLERS <br />REQUIRED <br />❑YES taNcf <br />MECHANICAL <br />Cx <br />APPROVALS <br />BY <br />DATE <br />OTHER <br />1 ENVIRONMENTAL CHECK LIST <br />PENALTY <br />U BC <br />SEC. 303(a) <br />2 BUILDING PLANS <br />TOTAL <br />�+ <br />S(J <br />S <br />3 FIRE HYDRANT <br />4 FIRE PROTECTION SYSTEM <br />5 GRADINGIEXCAVATIONACLEARINGIGRUBHING <br />PERMIT VALIDATION <br />WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT <br />6 DRAINAGE <br />7. ENVIRONMENTAL IMPACT STATEMENT <br />B HEALTH DISTRICT <br />APPLICATION ACC BY <br />PLANS CHECKED BY <br />I I W-?-J., <br />APPR FOR ISSUANCE BY <br />L . c.. <br />7 <br />R <br />9.1-79 <br />