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PPLICATION FO.. <br />the <br />CITY OFy°T«R <br />cln OF <br />CONSTRUCTION <br />[Y°T° N <br />everett <br />PERMIT <br />BUILDING DEPARTMENT <br />259.8745 <br />TO BE COMPLETED IN INK- PLEASE PRINT <br />❑ DEMOLITION <br />❑ COMBINATION ❑ BUILDING O MECHANICAL <br />�119-PLUMBING <br />❑ SIGN <br />OWNED <br />MUL AOORESR C" ZIP <br />PHONE <br />;Z - A/a Alks, C' <br />A SHaN IP�n I (•Z"`=s_7; &U�a�7- <br />3s3-v-71(" <br />ARCHITECT OR DESIGNER <br />MAIL ADDRESS CITY ZIP <br />PINNE <br />OENERAL CONTRACTOR <br />MAIL ADDRESS CITY TIP <br />PIIONF <br />LICENSE• <br />MECHANICAL CONIRAF.TOR <br />MAIL ADDRESS CITY ZIP <br />PHONE <br />LICENSE <br />PLUMBIN ICONIRACIOR <br />MAIL ADDRESS CITY ZIP <br />MIONE <br />LICENSE A <br />jaA%IrF I''LIIYNSIAV <br />Ilnr Q, Ic2l LIl,✓A,M,..,,1] tJJa <br />`lft�y/, 353 [yt�/ <br />7 <br />IbV�kzA <br />% <br />ClAlS Gr w K <br />❑ NEW ❑ ADDITION <br />❑ ALTERATION B. REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPL.INSERT <br />❑ BUILDING <br />RELOCATION <br />Y\LUATI NOr WOFI ICOST OF MAIENIALS <br />PLUS LABOR) <br />� � 65�1. (.It' <br />DESCRIBE WORK <br />PSI AI MJ L JA+I O_ <br />r' I PO ri <br />USE OE SUIT DING <br />IQ <br />ION.. , i I� j nM1 �' <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 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 OK <br />ANY OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION <br />OR THE PERFORMANCE OF CONSTRUCTION. <br />SIGNATURE /1 (CONTRACTOR OR AUTHORIZED AGENT DATE <br />LEGAL O[Sf:RIPTION Or POF.gRIYIS'IOwN SELOWOR 1TACH FOUR COMES) <br />PROJECT ADDRESS <br />III vaTull <br />AP%ICANTB CITYB MESSUCENSE NO <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTURE <br />FEE <br />NO. <br />TYPE OF EQUIPMENT <br />FEE <br />WATER CLOSET (TOILER <br />AIR COND. UNITS-H.P. EA <br />BATHTUB <br />REFRIGERATION UNITS-H.P. EA <br />LAVATORY WASH BASIN) <br />BOILERS-H. P. EA. <br />SHOWER <br />GAS FIRED AC. UNITS -TONNAGE EA <br />_ <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 -BTU. M <br />CLOTHES WASHER <br />C <br />EVAPORATIVE COOLERS <br />WATER HEATER <br />CLOTHES DRYERS <br />URINAL <br />VENTILATION FAN <br />DRINKING FOUNTAIN <br />RANGE HOOD <br />FLOOR DRAIN <br />AIR HANDLING UNIT- CF.M <br />VACUUM BREAKERS <br />STOVE <br />_ <br />ROOF DRAINS-RAINLEADERS <br />METAL FIREPLACE • CHIMNEY <br />_ <br />SINK (SERVICE -BAR. ETC.) <br />WOODSTOVE/FIREPLACE INSERT <br />ti/ 7 10,t yj c e= <br />BUR TOTAL <br />BUS TOTAL • <br />PLRMIT IT <br />PERMIT • <br />_ <br />TOTAL FEE • <br />3 <br />TOTALFEE • <br />THIS PORTION TO BE COMPLETED BY BUILDING DEPT. <br />PERSONNEL <br />FRONT SETBACK <br />PEAR SETBACK <br />SIDE SETBACK <br />PLAN CHECK NUMBER <br />PLAN <br />CHECK FEE <br />FEE <br />Rr CEIPI NO <br />USE EONE <br />to? AREA <br />VACANT SIFE <br />FEES <br />VALUATION <br />F[[ <br />OYES ONO <br />TYPE Or COIISI <br />OCCUPANCY GROUP <br />NO OF DWELLING UNRB <br />BUILDING <br />• <br />SIZE OF "IOU <br />NO OT STORIES <br />MAK. OCC LOAD <br />PLUMBING <br />MECHANICAL <br />FIRE SPRINKLERS REOUIRED O YES ❑ NO <br />OTHER <br />APPLICATION ACC BY PLANS CIIELKEO BY <br />APPq FOR ISSUANCE BY <br />PENALTY <br />TOTAL <br />