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APPLICATIO FOR CONSTRUC1'r ""'IN PERMIT <br />TO BE COMPLETED IN BLACK INK —PLEASE PRINT <br />HEATING SYSTEM• ❑ GAS ❑ ELECTRIC 0 --- <br />BUILDING DEPARTMENT <br />1(J f1 <br />259-8810 <br />i DEMOLITION <br />El COMBINATION �UILDINQ <br />❑MECHANICAL <br />_I <br />TIT <br />;rn�t Ula <br />MARADDRESS CITY <br />le -sib 1�3sisz: f�<..�tl <br />ZIP <br />9trao3 <br />PHC <br />.3 <br />PHC <br />TENANT <br />MAA ADORES9 CITY <br />ZIP <br />ARSPTEC \Op DESIGNER <br />I,- <br />MAIL ADDRESS CIT' <br />to I[-�avn L or. F j rT <br />ZIP <br />4d2d► <br />P� <br />a <br />❑ PLUMBING SIGN <br />CnY 21P PHONE �L BTATEL ENS, <br />" <br />GENERAL CONTRACTOR Gr MAIL ADDRESS p1J/"1' T <br />.Ci .y m r • CITY !IP PHCNE STATE LICENSE SE <br />MECHANICAL CONTRACTOR MAI. ADDRESS <br />PLLAABII IC CONTRACTOR MA'L LDOR... <br />CITY 21P PNONE SLATE IICENSEA <br />WORK <br />PROPOSED USE OF BUILDING <br />lEOAL DESCRIPTION OF PROPERTY IS)HOLYN BELOW OR ACH 7 W(9 COPIESI <br />LOT I BLOCK .--•J--- OF �fa�( <br />PARCEL TAXI NUMBER <br />CONSTRUCTION LOAN LEI <br />ROOF <br />SINK 1 <br />Oo3-vl/- too I. <br />III t� i s T s►= 10 .4— - <br />FOR OFFICE USE ONLY: <br />FRONT SETBA K RE <br />USE Z09 LOT AF <br />TYPELON T� NO OF <br />a <br />SIZE OF B-1 FIRE Si <br />1""o SF <br />CONTACT PERSCIN <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS <br />APPLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL <br />PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE OF <br />WORK WILL BE C('MPLETFD WITH WHETHER SPECIFIED HEREIN OR <br />NOT. THE GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE <br />AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY <br />OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION OR THE <br />PERFORMANCE AUTHORIZED <br />OWNER OF THIS PROPERTY TO PERFORM THE WORK FOR WHICH <br />APPLICATION IS MADE AND I COMOLY WITH THE STATE <br />CONTRACTORS LAW 18.27 RCW A 96.200 WAC. <br />)UF <br />Sans _ <br />T.U. <br />6ETl / <br />PUNCH CKNUMBER FEE <br />/ <br />""" _ <br />_ ,,1 / <br />VAL <br />FEES <br />FEES <br />ATION <br />FEE <br />,[ANT SITE <br />❑ YES ❑ NO <br />BuaowG <br />I <br />as�AGr MO aowulea U11I15 <br />I <br />� <br />PLUMBING <br />I <br />1SEMENT <br />MECHANICAL <br />❑ YES ❑ NO <br />I <br />�— <br />ADDITIONAL PLAN CHECK <br />EIGHT LI IT/LNON <br />�� <br />OTHER <br />I, <br />STATE BUILDING SURCHARGE <br />CITY OF EVERETT <br />PUBLIC WORK^• <br />LOCAL SALES <br />I <br />TAV ennc IS:1T05 <br />TOTAL <br />DATE <br />