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uMNISTRUCTION <br />PERMIT <br />APPLICATION <br />COMBINATION <br />• BUILDING <br />• MECHANICAL PLUMBING <br />OW NkN <br />MAIL ADONLSS <br />ZIP PRUNE <br />' CHITECi UII OESIUNLII <br />MAIL ADDRESS <br />PHONE LICLN51. NU <br />OENCRAL CONT RACTOR <br />MAILADORESS <br />- PHONE LICENSE NO. <br />MECHANICAL CONTRACTOR <br />MAIL ADDRESS <br />PHONE LICENSE NO. <br />►LUMUING CONT•RACTOH <br />MAILAOURESS <br />PHONE LICENSE NO. <br />PERMIT <br />CLASS Oi WORK <br />' <br />❑COMBINATION <br />[]BUILDING []PLUMBING ❑MECHANICAL ❑Ntw <br />❑ADDITION ❑ALTEIIAfl0N QHEPAIR <br />VALUATION OF WORK <br />❑Df MOLISH <br />❑FENCE ❑SIGN ❑':WIMMIN(i POOL <br />S <br />-- <br />DESCRIBE WORK <br />PROPOSED USE <br />OTHER PERMITS OR APPROVALS <br />•TJ RE ZONE .� SPECIAL USE <br />Lk6AL OkSCHIPTION OF PVOIE RT Y' (SNOW <br />FOUR COPIESI <br />BELOW OR ATTACH <br />7 <br />#VARIANCE SF!ORLINE <br />��••l1 <br />LOT BLOCK —OF �G�}`FL•Lt=1l <br />I� 1� <br />+-1 <br />SE PA CHECK LIST REQUIRED <br />= YES <br />�1 <br />]ZI NO <br />'LOB ADDRESS <br />Lot6'nA <br />rj {-y . <br />'MECHANICAL <br />PLUMBING <br />TYPE OF• ❑fi AS ENERGY ❑ELEC. <br />• <br />NO. TYPE OF EOUIPMCNT _ _ FEE <br />�Z <br />_ _ <br />AIR COND. UNITS_N.P. EA. 1 <br />NU. TYPE OF FIXTURE OR ITEM <br />FEE <br />Rti RiCERatiOi+ulil r5 /E P_EA _---�_—�-- <br />•— <br />NA111111US <br />_ <br />nO1L ER5 NP fA.---•! <br />1 <br />1 CLOTHES WASHER <br />I <br />_ <br />FORCED AIR SV STEMS B.T.U. ME A. <br />I, <br />UISII WASHEIIS <br />I <br />-- —' --•-_ 1 <br />011INK_ING FOUNTAINS <br />I• <br />SPACE_& WALL HEATERS -- P.T.U. _ r— <br />FI OD H DII AIMS <br />1 <br />UNIT HEATERS N.LV. <br />I <br />KI10rA—* SINKS P. 1 <br />I <br />EVAPORATIVE EMS <br />�, L <br />IIAII SINKS <br />HOOF DRAINS MAIN LEADERS ' <br />___ <br />CLO T11E5 ORr[ RS <br />1 <br />T <br />LSH01YkR OATHS <br />_ <br />VENTILATION TAN <br />SCrIVICE SINKS <br />RANGE HOOD _ 1 <br />SUMPS-- SEWAGE PUMP <br />AIR HANDLING UNIT C.F LM�� _• �_- <br />URINALS <br />._ .._ _ .._ <br />WATER CLOSE.15 <br />W <br />"'A'—� <br />. ... --- •_ _ <br />FAC. BUILT FIREPLACE h CI111ANLv <br />ASH nA51N5 <br />1 <br />_ - <br />GAS. SYSTEM: NO OP OUTLI IS,�� <br />LAUNDRY TRAYS <br />- F s <br />. <br />RMIT—S - <br />n <br />`_Y( <br />-- _— <br />-�-� TOTAL Fkk_S_ <br />L L <br />_ <br />SUD TOTAL <br />Tjjj.S VF.1i611T OECOM E_ NUI L AND VOID 11 Wc111K 1)N CUN_T RUC <br />S <br />TION AUIHORIZEO IS NOT f.DMMLNCED WITHIN 170 VAIr, OR IF <br />_PER_MIT _ <br />TOT1 _ <br />CUNSiRUCf10N OR WOIIK 11; SU:IPENDED On AIIANDONEH FOR A <br />PERIOD GI 120 DAYS AT ANY TIMk ni i[n wrnlK Ic Crrnlrak NCk D. <br />VATER SERVICE SIlE BLOO. <br />SUPPLY SIZE <br />I MERLRv CERTIFY TAUT 1 HAVE READ AND EXAMINI O TMIS A► <br />Cirm 1 L 1 - VA K <br />HkAN YARD SE 1tlAC K. <br />P LOCATION AND KNOW THE SAME TO Ill TRUE AND CORIM Ct. ALL <br />PROVISIONS OF LAWS AND ORDINANCES COVE RNINO IN15 TYPE <br />OF WORK WILL BE COMPLIED WI114 WI1ET11E Il SPECIFILO HEREIN <br />U5L IONL LOT AHLA <br />^� <br />NT61ikY <br />ORMIT III PRESUME TO <br />OR Tv TO IV OLNG 'Ark ORF A HCANCl LE 1,11i OPROVISIONS E)F <br />• <br />ES ❑NO <br />I <br />AUTI <br />ANY OTHER STATE OR LOCAL LAW HLOULATINU CONNTRUCTION <br />13R THE PERFORMANCE OI CONSTRUCTION <br />, <br />YPE OF CONST. O CUPANCV ORDUP F DWELLING <br />UNITS <br />EIZE OF BLDG.ZAVTQ_ NO.OF STORIkS <br />MAX. OCC. LOAD <br />1 <br />,9ATUIIEOFCONTRFCTORONAUTH AGENT DATE <br />�LnO <br />1111 l)N�— <br />1111 E1 d'111NK1L CIIS <br />S <br />�� <br />IIA(ikA./ZNI <br />HL1I <br />PLAN CHLCK ILL <br />RLOU1 <br />❑YES No <br />LAN GILCK NDMtlIII <br />It[ RECEIPT NH, <br />IPLCIAC CONDITIONS: <br />. <br />FEES VArLUATITO-N. - _•Ff-.� <br />_ <br />t <br />II,,• <br />BUILOIN6 S `FCI 7- <br />WA REVIEW COMPLETE: OYES [INOPLHMnIN° <br />_- — - 0 <br />1 <br />��0 <br />' j C1 ;(N, <br />Contact PIOnnIOQ dept. <br />MLCIIANICAL <br />onitR 1 <br />1•IKA11UN aunlu Yl .uXTwlauuP. <br />AIr•ovlo o•rwaXcln <br />PENALTY SEC. 00310 1 <br />TOTAL �.� _..-_...__�.. %%.r•-L�� <br />