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� �i <br /> rn.e�.�v�een Pw�� 0..'�/'A ! �� 1 V �� � evcrett I' <br /> ��n�F ��NSTf�UCTi� N �y <br /> �V�i'�tt PERsi� 9T <br /> BUILDING DePARTME�!T <br /> 259-8870 TO BE COMPLETED IN INK - PLEASE PRINT I <br /> ❑ DEMOLITION ❑ COMBINATION ,$(BUILDING ❑ MECHANICAL. ❑ PLUMBING ❑ SIGN I <br /> ocmen // Mni�nonncss an� �-- ano�.e (e7/-�i/ S�8 � <br /> �CCi"dL'� I_Qh.S�CYe�/d N C'a � TI�C . .7Q1_.S�`��S/�. /�e.J—N/e„�A/�r W t[. es�'.0�' li <br /> qq IIIIEC1U11UESIGNER IAFILAO�RF.S$ CIrV ilP� p�LL '-' –�� � <br /> �tt�6NtLGON1f+nClOn Mall n�JH[55 C�'/ /��' vupNF LiCEuSE• <br /> /LIILVG��ok s7�y�c�i✓h �o ,Ik c, �o/�,-� S/'=S�� //� ��t-� l,vr� _ <br /> MECIIrNiC�ICONin4GlOq MARPpDRE`.ig !'If! ZIV PHONE <br /> ^ D•cll$f• <br /> ��j�� � /l/�. / <br /> �lITT'���� � <br /> VW!.�B �;CONIP�CTO(a / 6+nn/.Ap04]Jli$ J�'! ZIN PIIONE �ICB+St• <br /> - U.2," �/U/�'!P/.t1 !f <br /> cinss� --� . <br /> ❑ NEW ❑ ADDI710N ❑ ALTERATION ❑ REPAIR ❑ DEMOLir10N ❑ WOOOSTOVE;PRPL.INSERT ❑ BUILOf�VG REL�ICATION <br /> v.+wF*iou or tion..�.�ost o�r.ut[Fi�.u;rw,v'lafloei <br /> ��L� / <br /> ✓ r / <br /> DEb^Pi WJHrc <br /> �') ,�.�- <br /> usc oF eun.o�rm — <br /> 1 HERE-BY CERTIFY THAT I HAVE READ AND EXAMIMED THIS.IP� <br /> PLICATION AND KNOW THE SAME TO RE TRUE AivD COARECT.ALL <br /> �ecn�ocsca�rnor+oFcaorearvisnowr�ee�owoA�.r�na��o,incoricsi pROVISIONSOFLAWSANDORDINANCESGOVEFNINGTHISTYPE <br /> � � � ' ar� It� OFWORKINILLBECOMPLETEDWITHWHETHERSPECIFIEDHERE <br /> io�—o.oc�—oF IN OR NOT.THE GRANTING OF A PERMIT DOES NOT PRE4UME TO <br /> GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF <br /> ANV OTHER STATE OR LOCAL LA'N REGULATING CONSTRUCTION <br /> OR THE PERFORMANCE OF CONSTRUCTION. <br /> SIGYAitIR[pF GONIR4CTOR O�.Uir!pq¢ED AGE T I1A76 <br /> X - -_�_ <br /> PRpJF.CI AppqE55 APPLIG I'l(..i r]U:+•�L511'[:"IlSC Nf <br /> l0 9� ss -�D"' /Jn se <br /> PLUMBING MECHANICAL <br /> NO. TYPE OF FIXTURE OR ITEM FEE NO. TYPE OF EOUIPMENT FEE <br /> � WATER CLOSET�TOILET) nrC-AiHN�IG UNIT$-H P <br /> 2 6A1'HTUB REFFIGERATION UNITS-H P GA. <br /> � tl1VATOfl/�WA!iH8A51N1 � '� BOILER$-BSUiHP <br /> SHOWER GAS FIRED A C.UNITS-B.T.U. <br /> KITCHEN SINK 8 DISP. —_ FOFCED AIR SVSTEMS-B TL. M EA <br /> OISHWASHEfl WALLHEATERS-BTL. M <br /> LAUNOFV T'VAY UNIT HEl�TEiiS-8 T U M <br /> � CIOTHESIVnSHER PJAPOf�ATIVECOOLEFS <br /> URINAL CLOTHESORVERS <br /> DRINKING I°OUNTAIN VENTLLA7ION FAN <br /> FLOOR DFnIN I RANGE HOOD <br /> BACKFLOW PFEVENTERS WFTERHEATER y <br /> ROOF�RAINS-RAINLEAOERS WOODSTOVE <br /> SINK(SERVICE-BAR.ETC� METAL FIPEPLA�:C 8 CHIMNEV <br /> FIREPL�CEINSERT � <br /> HEA. PUMP <br /> G�S PIPING <br /> EXHAUSTF4N <br /> SUBTOTAL 5 �� SUBTOTAL <br /> PERMIT 5 PEHMIT <br />� TOTALFEE S V TOTALFEE <br /> r'1�1N i;M K N�MdER FEE AECEIPT NO <br /> iuLbI5F1(3ACf. REAHSEfBACK Si[)ESEIBPLK ( <br /> r � , <br /> ��> �S. �. �=� I�%C�� l__ �l <br /> usE�aH/-J �ornaEn �a�p��r�irE FEES VALUATION FEE <br /> �.- I �I c?y � ,res �r�o <br /> eui�owc 5��� � � =1�' J�� � �'�\ <br /> fY['[O� f.('�45i OCCUPFNCY GFpUP f!O OF DWFLLI4G UNIiS <br /> �� R � 3 / PLUMBING L �� �� `� <br /> SiTFO�BIDG NO OF STURIES MA% OCG IOFD <br /> /ZZ'� / MECHAIJIUL f�'; �n <br /> ; A � ,��" <br /> OTHER <br /> FIRE SPRINKLERS F[OUIRED ❑ YES hc'FJO .� 6-" <br /> STATE BUILDING SUi7CHAFG[ �,� ��� <br /> S7AiE ENERGY SURCHAPGE r t � ! <br /> :.����.��.�����.�� �: a• ��rvsc��ecKeoev nri�Hrouissunr+cEor <br /> -y Pl1BLIC WORKS ��� 1 n� � <br /> / � /`_ TOTAL �`,:', 1 �-�(. <br /> I <br /> 1=ROPERTY OWNERS�RE FESPONSIBLE FOR DETERMIN WG ALL <br /> PROPERTV LW[LOCATIONSAND RELAT[D EASEMENTS. <br />