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I <br />1 PPLICATION FO1' <br />Gr« "" CONSTRUCTION e <br />everett PERMIT <br />BUILDING DEPARTMENT 259•8810 TO BE COMPLETED IN INK • PLEASE PRINT <br />I <br />❑ DEMOLITION <br />❑ COMBINATION <br />❑ BUILDING O'MECHANICAL <br />O'PLUMBING ❑ SIGN <br />OWNER r <br />1(7 <br />MAIL ADDRESS <br />`,l�I'\IL� <br />CITY ZIP <br />PHONE <br />ARCHITECT OR DESIGNER <br />MAIL ADDRESS <br />CITY 2�P <br />PHONE <br />GENERAL CONTRACTOR <br />MAIL ADDRESS <br />CITY ZIP <br />PHONE LICENSE• <br />MECHANICAL CONTRACTOR <br />MAIL ADDRESS <br />CITY ZIP <br />PHONE LICENSE <br />/t) fii tl2C(� �1(D <br />PW ME IN G CON T RAC TOR <br />MAIL ADDRESS <br />CITY 21P <br />PIIONE LICENSER <br />CLASS OF WORK <br />❑ NEW ❑ ADDITION 0 ALTERATION ❑ REPAIR Cl DEMOLITION Cl WOODSTOVE/FRPL.INSERT Cl BUILDING RELOCATION <br />VALUAPON OF WORK(COST OF MATERIALS PLUS LABORI <br />DESQRIBE WORK <br />t( 10'1.k,tu((Tfir)t-1on1 rt <br />usE OF euILDINc rp <br />•."Ih� �l�=����)II�� <br />1 HEREBY CERTIFY THAT I HAVE READ A4 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 COMPLETED WITH WHETHER SPECIFIED HERE- <br />IN OR NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO <br />GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF <br />ANYOTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION <br />OR THE PERFORMANCE OF CONSTRUCTION. <br />SIGNATU EOF CONTRACTOR OR AUTHORIZED AGENT DATE <br />X 1 <br />, ' � 4 111, <br />LEGAL DESCRIPTION OF VOPERTY(SHOWN BELOW OR ATTACHE URCOPIESI <br />LOT- BLOCK OF <br />_ <br />PROJECT ADDRESS <br />APPLICANTS CITY BUSINESS LICENSE NO <br />PLUMBING <br />MECHANICAL <br />NO. TYPE OF EOUIPMEIIT FEE <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />WATER CLOSET (TOILET) <br />A/C — AIHNOLG UNITS — H P. <br />BATHTUB <br />REFRIGERATION UNITS — H.P. EA. <br />LAVATORY (WASH BASIN) <br />BOILERS — B.T.U.iH P <br />I <br />SHOWER <br />GAS FIRED ABC. UNITS — B.T.U. <br />KITCHEN SINK & DISP. <br />FORCED AIR SYSTEMS — B T.U. M EA. <br />DISHWASHER <br />WAtU HEATERS —B. T.U.(Jjpl^t M <br />LAUNDRY TRAY <br />UNIT HEATERS — B.T U. M <br />CLOTHES WASHER <br />EVAPORATIVE COOLERS <br />URINAL <br />CLOTHES DRYERS <br />DRINKING FOUNTAIN <br />VENTILATION FAN <br />FLOOR DRAIN - <br />RANGE HOOD <br />BACKFLOW PREVENT ERS <br />WATER HEATER <br />ROOF DRAINS — RAINLEADERS <br />WOOD STOVE <br />SINK (SERVICE —BAR. ETC) <br />METAL FIREPLACE & CHIMNEY <br />FIREPLACE INSERT <br />HEAT PUMP <br />GAS PIPING <br />EXHAUSTFAN <br />SUB TOTAL <br />f <br />SUBTOTAL <br />PERMIT <br />f <br />PERMIT <br />TOTAL FEE <br />sl <br />TOTAL FEE III <br />PLAN CHECK NUMBER <br />FEE <br />RECEIPT NO. <br />FRONT SETBACK <br />REAR SETBACK <br />SIDE SETBACK <br />USE ZONE <br />LOTAREA <br />VACANT SITE <br />OYES ONO <br />FEES <br />VALUATION <br />FEE <br />BUILDING <br />S <br />TYPE OF CONST. <br />OCCUPANCY GROUP <br />NO. OF DWELLING UNITS <br />PLUMBING <br />SIZE OF BLDG <br />NO OF STORIES <br />MAX OCC LOAD <br />MECHANICAL <br />OTHER <br />FIRE SPRINKLERS REQUIRED ❑ YES ❑ NO <br />STATE BUILDING SURCHARGE <br />STATE ENERGY SURCHARGE <br />APPLICATIO14ACC BY <br />PLANS CHECKED BY <br />APPR FOR ISSUANCE BY <br />PUBLIC WORKS <br />TOTAL <br />4 <br />YHVYCMI T VYVIVCnJ MHC T\GJrVnmu.L � vn ��lommma n..•. <br />PROPERTY LINE LOCATIONS AND RELATED EASEMENTS. <br />