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cry »B `'r.PPLICATION FOn [Y[F[N <br />everett CONPERMITTION e <br />TO BE COMPLETED IN BLACK INK — PLEASE PRINT <br />BUILDING DEPT. <br />259.8745 ❑ COMBINATION ❑ BUILDING MECHANICAL ❑ PLUMBING ❑ SIGN <br />OWNER <br />�I) �1 MAIL ADDRES <br />S <br />ZIP PHONE <br />--� ?Li— f /'/L '- T t F / 7i / - /o : 3,ns� .i';(. ii 1...1.'7'iY_� <br />GENERAL CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE F <br />MECHANICAL CONTRACTOR MAIL ADDRESS ./ CITY ZIP PHONE LICENSE• <br />�'...... 1).A,, .4 •if-, /•'_.- //.f1a A-le,YTYn'i Aw7PA (.Lw-<71P✓ .3" 77 Ti: 17/l LLf ILA /S-9L1 <br />❑ NEW ❑ ADDITION (J ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPLANSERT ❑ BUILDING RELOCATION <br />VAL UADON O'iyF WORK 10081 Or MATERIALS PLUS LABORI <br />>SC% is' — <br />DESCRIBE WORK <br />USE Or BGILDING <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP• <br />PLICATION AND KNO W TH E SAME TO BE TRUE AND CORRECT. ALL <br />PROVISIONS OF LAWSAND 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 />ANY OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION <br />OR T P RFORMANCE OF CONSTRUCTION. <br />SIGN 7E F ACtOp OR &U7HORIZED AGENT DATE <br />r <br />LEGAL DESCRIPTION OF PROPERTY ISHOWN BELOW OR ATTACH FOUR COPIES) <br />IOr_BLOCKOF <br />PROJECT ADDRESS <br />- _ 1 �I t.• r. r I <br />APPLICAN BCIIY BU91 SLOILENSE NO <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTURE <br />FEE <br />NO. <br />TYPE OF EOUIPMENT <br />FEE <br />WATER CLOSET TOILE <br />AIR CONO. UNITS-H.P. EA. <br />BATHTUB <br />REFRIGERATION UNITS-H. P. EA, <br />LAVATORY JWASH BASIN <br />BOILERS-H. P. EA <br />SHOWER <br />OAS FIRED AC. UNITS-IONNAGE EA <br />KITCHEN SINKII DISP. <br />FORCED AIR SYSTEMS-B.T.U. M EA _ <br />DISHWASHER <br />WALL HEATERS-B.T.U. M <br />LAUNDRY TRAY <br />UNIT HEATERS-B.T.U. M <br />CLOTHES WASHER <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- C.F.M. <br />_ <br />_ <br />VACUUM BREAKERS <br />STOVE <br />ROOF DRAINS-RAINLEADERS <br />METAL FIREPLACE A CHIMNEY <br />SINK SERVICE -BAR, ETC <br />WOODSTOVE/FIREPLACE INSERT <br />SUBTOTAL <br />SUB TOTAL B <br />_ <br />:..RMIT f <br />PERMIT f <br />_ <br />TOTALFEE S <br />TOTALFEE B <br />THIS PORTION TO BE COMPLETED BY BUILDING DEPT. PERSONNEL <br />I RONI BE TBACK RLAH SEIBACK SIDE SEIDACK PLAN CHECK NUMBLR IKAN CIH CA I EE <br />FEE RECEIPT NO <br />USE ZONE LOT AREA VACANT SITE <br />![E6 YALUATI <br />OYES ONO <br />TYPE OF CONS1 OCCUPANCY GROUP NO OF DWELLING UN178- <br />BUILDINO [ <br />SIZE OF BLDO NO Or SIO"IES MAX OCO LOAD <br />PLUMBING <br />MECHANICAL <br />FIRE SPRINKLERS RLOUIREO ❑ YL`' J NO <br />- OTHER <br />PENALTY <br />APPLICATION ACC BY PLANS CHECKED BY APPR TFAN 198UANCE BY -- <br />TOTAL <br />