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the Evergreen <br />CITY OF <br />everett <br />BUILDING DEPARTMENT <br />259.8745 <br />_TPLICATION FOF__ w <br />CONSTRUCTION <br />PERMIT <br />TO BE COMPLETED IN INK- PLEASE PRINT <br />❑ DEMOLITION ❑ COMBINATION ❑ BUILDING ❑ MECHANICAL ❑ PLUMBING KSIGN <br />OWNER MAIL ADDRESS CITY ZIP PHONE <br />�19�1� 2@ i Y �'i5iJ5 i eyn c 14, <br />ARCHITECT OR DESIGNER MAIL ADOPESS CITY ZIP PHONE <br />GENERAL CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE• <br />J'sn y N3v/ Cd _:iwc PC, aoK 4-4- 98"UY(, 77G S>i 3" R' AW 2Y7 LN, <br />MECHANICAL CONTRACTOR MAIL ADDRESS CITY LIP PHONE LICENSE F <br />PLUMBING CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE <br />9NEW ❑ AODiTION ❑ ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPL.INSERT ❑ BUILDING RELOCATION <br />VAL,/W TION O/F WOR^�N,�ICOBi Of MMLRMLn PLUS LABOR, <br />S�CiOV . r)(. <br />DESCRIBE WORK <br />FhflR'LrM YTS rf -21X es I .D /r- �I i�rzYVA c�Y 77_� UI.aDt'AilY9 S n�T/ <br />USE OF BUILDING <br />omm LEA-�,Z�K _ <br />='"�' <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP- <br />PLICATIONAND KNOW THE SAME TO BE TRUE AND CORRECT. ALL <br />PROVISIONSOF LAWS AND ORDINANCES GOVE RNI NG THIS TYPE <br />OF WORK WILL BE COMPLETED WITH WHETHER SPECIFIED HERE- <br />IN OR NOT. THE GRANTING OF A PERMITDOES 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 C NTRACTOR OR AUTHORIZED AGENT DATE <br />X <br />APPLICANTS ITY BUSINESSLICQJSE NO <br />31`i6:57 <br />LEGAL DESCRIPTION OF PROPERTYISFIOWN BELOW OR ATTACH FOUR COPIES, <br />LOT_BLOCK —OF <br />PROJECT ADDRESS <br />1 50�3-- /-IU405 sL- <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTURE <br />FEE' <br />NO, <br />TYPE OF EOUIPMENT <br />FEE <br />WATER CLOSET (TOILET) <br />AIR COND. UNITS—H.P. EA. <br />_ <br />BATHTUB <br />_ <br />REFRIGERATION UNITS—H.P. EA. <br />LAVATORY (WASH BASIN) <br />BOILERS—H.P. EA. <br />SHOWER <br />GAS FIRED A.C. UNITS —TONNAGE EA. <br />KITCHEN SINK A DISP. <br />FORCED AIR SYSTEMS—B.T.U. M EA. <br />DISHWASHER <br />WALL HEATERS—B.T.U. M <br />LAUNDRYTRAY _ <br />UNIT HEATERS—B.T.U. M <br />CLOTHES WASHER <br />EVAPORATIVE COOLERS <br />WATER HEATER <br />_ <br />CLOTHES DRYLRS <br />URINAL <br />_ <br />VENTILATION FAN <br />DRINKING FOUNTAIN <br />RANGE HOOD <br />FLOOR DRAIN <br />_ <br />AIR HANDLING UNIT— C.F,M. <br />VACUUM BREAKERS <br />STOVE_ <br />_ <br />ROOF DRAINS—RAINLEADERS <br />METAL FIREPLACE& CHIMNEY <br />SINK SERVICE —BAR. ETC <br />WOODSTOVE/FIREPLACE INSERT <br />SUB TOTAL <br />SUB TOTAL S <br />PERMIT S <br />PERMIT S <br />_ <br />_- <br />TOTALFEE S <br />TOTAL FEE S, <br />THIS PORTION TO BE COMPLETED BY BUILDING DEPT. PERSONNEL <br />FRONT SETBACK <br />REAR SETBACK <br />SIDE SETBACK <br />PLAN CHECK NUMBER <br />-LAN <br />FEE <br />CHECK FEE <br />RECEIPT N0. <br />USE ZONE <br />LOTAnFA <br />VACANT SITE <br />❑YES ONO <br />FEES — <br />-- <br />VALUATION <br />FEE <br />TYPE OF CONST. <br />OCCUPANCY GROUP <br />NO OF DWELLING UNITS <br />BUILDING <br />S <br />SIZE OF BLDG <br />NO. OF STORIES <br />MAX. OCC. LOAD <br />PLUMBING <br />FIRE SPRINKLERS REQUIRED LI YES ❑ NO <br />MECHANICAL <br />OTHER <br />— <br />PENALTY <br />APPLICATION ACC BY <br />PLANS CHECKED BY <br />I APPN. FOR ISSUANC6BY <br />�I oGI TOTAL <br />�Vll 2 -�Q-j�T <br />