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,�E,,,�,,,,, APPLICATION FJR ���,�„ <br />everett CONPERMITTION � <br />TO BE COMPLETEJ IN BLACK INK — PLEASE PRINT <br />BUILDING DEPT. <br />259•8745 � COMHiNATION � BUILDING � MECHANICAL � PLUMBING ❑ SIGN <br />�j,q./i � NNL�DOPE55 Gtt ZIP PIIONL <br />21P <br />� <br />� <br />� � (���sT`rae�r�s1 //3 s /�'� f'. 6G� ,�'�rr�eH 1r'��o'Y _SY7/y_2_> Ao,iE,l'N :x�9L, <br />ME NIULf.ORTPACTOfl M.11lADOHE54 CITY 21P I'uOl�f IIf.CN91.• <br />PIIIMBINGCONTfl�CTOR MAILAOOflESG CPY c.. 1'Iwl❑ Iif.IIL•;I • <br />L1A550F WOPR <br />�. NEW ❑ ADDITION ❑ ALTFiFATION ❑ REPAIR ❑ DENOLITION ❑ WOODSTOVE/FRPL.INSERT ❑ BIIILDINC, qELOCAiION <br />vnineiom-uiw�nu.nu�:i��n�.i+iiiva•�rius�niiniu ��.� <br />Ll7_e�e '�•�� /__'% /°)!��/�. ��'" <br />WONN <br />ior� <br />7 <br />�� <br />Ofl <br />, �. <br />�7��-��i r_.,. -�•LC). <br />VACUUM BREAKERS <br />pOOF �RAINS-RAINLEAOERS <br />SINHISERVICE-BAR.ETC.� <br />I Ht�:REBY CERTIFY THAT I HAVE READ AND EXAMINFD THlS AP� <br />PLICATION AND KPlOW THE SAMETO BE TRUE AND CORRECT. ALl <br />PROVISIO�'S OF LAWSAND ORDINANCES GOV�RNING TIIISTYPE <br />OF WORK WILL BE COMPLETED WITH WHETfiER SPECIFIED hiERE- <br />IN OR NOT. THE GRANTING OF A PERMIT DOES tJOT PRESUME TO <br />GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF <br />ANY OTHER STATE OR LOCAL LAW RE(;IILATING CONSTRUCTION <br />JR THE PERFORMANCE OF CONSTRUCTION. p <br />SIGNATl1RE OF CONTRACTOfl Ofl AUTHUHIZE[l AGENf DATE /�S—� 7 6 <br />X �' � �,s l% <br />IE EA <br />M EA. <br />FEE <br />CLO7HES CflYEflS _ _ <br />VENTII.ATION FAN _" __ __._ <br />RANGEHOG� __..____ <br />AIR HANDI.ING UNIT- C.F.M _ _ _ _ __ <br />S70VE __ _._— <br />__.-.— s .Y_ _ � �c'. <br />-s ___ _ `_.s-,. <br />__. ___. s ______ -): I'"JC.,� <br />----- -- - l . .. - <br />TFiIS PORTION TO BE COMPLETED BY BUILDING DEPT. PERSONNEL <br />1CK I REaFi SETBlACK SIOE SETBA/CN P:AN CMECK Nt1MBER 1'yAl� CM�Cn f kl. <br />�� :/t/ I Ca� '" / / �Q �7 FEE � ^ y � — ll6f.ttl�Illct �5/ ..__.-. <br />LOTRq[A (� / ` J L/ <br />V1 C�NTSITE FEES VALUATION FEE <br />\�C ( lI n .... WYES ONO _'_—_" "—" _—_—_ _"__ I... . <br />tl-N <br />= r U�OG �: ��'. <br />1�_.i �"�%�ir, <br />��� '. �i�.:('�' <br />ALC BY <br />1 �: .p <br />OLLIIPPNCY <br />�� -- <br />ISCNECKEDBY I�PPR.FORISSWNCEI <br />G G <br />eui�owc <br />PLUMOING <br />MECH".NICAL <br />OTNEfl <br />PENALTY <br />TOTRL <br />f� t) �1 � <br />_L:�:. �._�_ <br />�/ . 7 �_?L. � <br />_.—__Y.. 4: . �- <br />1 r. i <br />.J� . � <br />