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uu.,V.) I f(Ul, I IUIV <br />PERMIT APPLICATION <br />COMBINATION it BUILDING • MECHANICAL • PLUMBING <br />JY. rat -MAIL AUUIIkSS' AY PBVNL ---- <br />AlIC111TECf UII'DCSIIFNkN MAIL ADOII SS ►HONIL LICLNSL ----"" - <br />ROKE n4L CONi NACTOR MMLADDnLSS PHONE LICE N!M NU ---- - <br />ALCHANICAL CONTRACTOR MAIL ADDRESS PHONE LICENSE NO. <br />'LUMUING CONT,RACTOH MAIL ADDRESS PHONE LICENSE NO. <br />'Ci1MIT <br />❑ COMOINATION <br />❑ BUILDING ❑ PLUMBING ❑ MECIIANICAL <br />/ALUAf10N Di WORK <br />S <br />CLASS OF WORK -- <br />' <br />' <br />❑NEW ❑ADOITIUN ❑ALTEIIA f1UN ❑IILI'Alll <br />❑DEMOLISH ❑FEf.CE ❑SIGN ❑•AYIA/M)Nti POOL. <br />)ESCRIOL WORK <br />RUPOSEO USE <br />OTHER PERMITS OR APPROVALS <br />REZONE SPECIAL USE <br />VARIANCE SF'.ORLINE <br />�I <br />I -At 6—k5FRIPTION of PnOFLnTY (SHOW BELOW OR ATTACH <br />G NCr�O►IESI <br />OT.�C._ BLOCK —OF SG�'�N -zee D �Af <br />5EPA CHECK LIST REQUIRED <br />]� YES <br />3:1' NO <br />(J <br />JB ADORf55�iI� � L <br />%S/l-T <br />LUMBINCr' -- <br />)MECHANICAL <br />TYPE OF ENERGY ❑OAS• ❑fuc. <br />NO. _ TYPE OF EOUIPMC NT_ <br />Ain CONO. UNITS-IEP. EA. <br />R6dR CC;f ntItin Ufil IS— ITV L4. —T— <br />BOILERS I/P FA. - --_--" —� j— <br />fU OCED Alll SYSTEMS ILI.V. AIC A. ------� <br />••— ---••-•---•- L- <br />SPACE 6 WALL HEATERS •• n.T.U. _ T_ <br />10. <br />TYPE OF FIXTURE OR ITEM <br />_ <br />FEE <br />;r, <br />IIA_IH IIIUS <br />S <br />'1 <br />C.01HES WASI/hH <br />' <br />� <br />UI511 VlASHE115 <br />I <br />DIIINKING FOUNTAINS <br />FI OOH OIIA INS <br />ri- <br />KITCtON SIFIKS h OISP. <br />I <br />UNIT BEATERS 11.T.U. <br />IIAII SINKS <br />EVAPORATIVE COOLEN_S <br />HOOF DIIAINS RAIN LEADERS <br />CLD HIES DnYEnS <br />1 <br />_. <br />LSIIDLVEn RATIIS <br />y <br />_ <br />VENTILATIONFAN <br />%VIVICE SINKS <br />RANGE If000 _ _ 1 <br />-- <br />_ AIn11C• .ANOLINUf1I1- •• C:.r.FA, <br />WATER HEATER- __. .. -.. •. _. <br />_ ♦^�— <br />_ fAC. GUILT rIR CPLACE_A CIIIMNCY <br />GAS. SYSTEM: NO OP OUTLt IS - <br />- - "dun I( s `_ <br />..—_..�.... pERMI7--'S .. .. iI�-Y.•Y <br />TOTAL <br />11iiin Pk iil-iii BECOMES NUI 1. ANii VOID 11 )VBIIK .1H CIINSTnUC <br />TION AUtUDNIlED IS NBt COMMLIJCI O WITIfIN 170 DAY!;. On IF <br />CUNSTntICftON On WOIIK I!{ !:U1P•1 NBCD On AIIANDONLD TOII A <br />PERIOD of 170 DAYS AT ANY nMII At TE11 WORK Is CN•er..l NCLD <br />I IIEt1E11Y CERTIFY IHAI I IIAVL Ifl'AO AND E<A1. f.in TniS AP <br />PLICATI(IN AND KNOW III[ SAME IO III. TFtLIE AND C01011 CT. ALL <br />PROVISIONS OF LAWS AND OIIDINANCES DOVE FINING Lff'S TYPE <br />OF WOnK WILL BE COMPLIED WItIf PnfLTHLn SPCCIFIID Ifrnlf•. <br />OR NOT, TIIE GIIANTING OF A PERMIT DOE!. NDT PNESUMC TO <br />GIVE. AUT11OF41TY TO VIDLAFI. OR CANCkl. T11E I'n(IV1SIONS OF <br />ANY OTIIEFI STATE On LOCAL LAW HL({UI.A(INti GONST1fUCI ION <br />Oil TIIE PERFORMANCE Of CONSI RUC I ION <br />F <br />X <br />_SUMPS SEIVA(iF PUMP <br />URINALS <br />4- <br />WATERCLOSE.TS <br />WA14111H.A1E11S - ELCCTnIC <br />t <br />1VA:iH BASINS <br />1 <br />LAUNDRY TIIAYs <br />-�— <br />SUB TOTAL <br />1 <br />PE_p AflT <br />S -� <br />T _ E <br />ITEn SERVICE SIZE BLDG. SUPPLY SRk <br />l� "it •11!, f. <br />'.L LUNI <br />11 - UACK Hl <br />LUl AIILA VACANT <br />' <br />All lAllU 9L IUACF.. <br />SITk <br />OYES ONO <br />IPE OOI CONST. <br />OCCUPANCY GROUP NO.Of <br />UNITS <br />OWL LL LNG <br />LE OF OLOG.•u,t -ta <br />L J1 d <br />NO.OF STORI LS MA <br />Z. <br />IIAI:k MLNt t"110YES <br />K. 0CC. LOAD <br />llt !d4UNkl.IILG <br />OUIHLU ONO <br />1/L OI/ <br />SIGNATURE OF CONT/IACTOn DII AVTII.ANENT DATE <br />L.IN LIII CK NUMUU/ PLAN GIIIIECEIP <br />I LC GECUPt NIL, <br />FEES VALVATION FE <br />LCIAI' CONDITIONS: <br />OUILDING <br />''LL'M'nN'E <br />MLCIIANICAL—•�• <br />• <br />��iUG <br />�� la� <br />j <br />iEPA REVIEW COMPLETE: DYES ❑ NO O — <br />COnIOCI plonnlnq depl. <br />' <br />•KwIgNTuuNUIIT ruriLnttuUrr or VI�wiKlIV <br />OTIICR <br />PENALTY <br />TOTAL <br />SIC. 000111 <br />r •t [l 1 �1O <br />1F <br />4 P• I - t _. <br />