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The Evergreen <br />CITY OF <br />everett <br />BUILDING DEPARTMENT <br />259-0010 <br />APPLICLION FOR CONSTRU%oTION <br />PERMIT <br />TO BE COMPLETED IN INK - PLEASE PRINT <br />OWNER MAIL ADDRESS ClTv ZIP PHONE <br />� rec E N Till ns+.S�c a�aI- I I(p", C-r. - -�leret� 913aoB 33-7 7153 <br />TENANT 7MAIL ADDRESS CITY ZIP PHONE <br />ARCHITECT OR DESIGNER MAIL ADDRESS CITY ZIP PHONE <br />PLUMBING CONTRACTOR MAIL ADDRESS CITY ZIP PHONE LICENSE <br />CLA890F <br />NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ WOOOSTOVFJFRPLINSERT ❑ BUILDINGRELOCATION <br />TENANT IMPROVEMENT OR INTERIOR REMMILL�O(NLT <br />WeONTRACT PRICE OF WORK <br />` <br />CONTACT PERSON AND PHONE NO <br />DESCRIBE WORK AND SQUARE FOOTAGE I IVOLVEO <br />M9ED USE OF BUILDING <br />S F <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION AND <br />KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS AND <br />ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLETED WITH <br />WHETHER SPECIFIED HEREINOR NOT. THE GRANTING OFA PERMIT DOES NOT <br />PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF <br />ANYOTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION OR THE PER- <br />OF CONSTRUCTION. THAT I AM AUTHORIZED BY THE OWNER OF <br />THIS PROPERTY TO PERFORM THE WORK FOR WHICH APPLICATION IS MADE <br />AND I COMPLY WITH THE STATE CONTRACTORS LAW 10.27 RCW AND <br />296200 WAG <br />IGXSIGNATURE OF CONTRACTOR OnAUTHORIZED AGENT DATE r �Z ; - 9,3 <br />APPLICANTSgT ICENS OANOBUSINESS NAME• 7_L <br />LL i <br />LEGAL DESCRIPTION OF PROPERIYIBNOWN BELOW OR ATTACH FOUR COPIER <br />nn <br />LOTa _ BLOCK__ OF CL(L l 2 d CA <br />LOT <br />— <br />PRO,IECTADDRES9 <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />NO. TYPE OF EQUIPMENT <br />FEE <br />WATER CLOSET (TOILET) <br />NC - NHNDLG UNITS - H.P. <br />BATHTUB <br />FORCED AIR SYSTEMS- BT.U. M EA <br />LAVATORY (WASH BASIN) <br />UNIT HEATERS -BTU. M <br />SHOWER <br />CLOTHESDRYERS <br />KITCHEN SINK S DISP. <br />VENTILATION FAN <br />DISHWASHER <br />RANGE HOOD <br />LAUNDRY TRAY <br />WATER HEATER <br />CLOTHES WASHER <br />r <br />WOOD STOVE <br />URINAL <br />METAL FIREPLACES CHIMNEY <br />DRINKING FOUNTAIN <br />FIREPLACE INSERT <br />FLOOR DRAIN <br />HEAT PUMP <br />BACKFLOW PREVENTERS <br />OAS PIPING <br />ROOF DRAINS - RAINLEADERS <br />EXHAUST FAN <br />SINK (SERVICE - BAR, ETC( <br />SUBTOTAL S <br />SUBTOTAL S <br />_ <br />PERMIT S <br />PERMIT S <br />_ <br />TOTAL FEE III'� <br />TOTAL FEE S <br />FRONT SETBACK <br />REAR SETBACK <br />SIDE SETBACK <br />/LAN CH <br />CK NUMBER <br />�� ►a <br />FEE <br />— <br />RECEIPTN <br />U9E20 E <br />�(,S-100 <br />L01 MEA <br />V,CMTSIIE <br />YEB ONO <br />FEES <br />VALUATION <br />FEE <br />BUILDING _- <br />PLUMBING <br />MECHANICAL <br />S 0 <br />TYPE OF WHIST <br />ALLOWABLE/ACTUAL <br />OCCUPoWCYGROUP <br />NO OF DWELLING UNITS <br />SIZE Of ULDO <br />1 <br />NO OF STORIES <br />I <br />BSMT. <br />a r <br />N <br />Q:C LWD <br />N <br />OTHER <br />FIRE BPRINKLERS REQUIRED OYES KNO <br />HEION IMI AWN <br />STATE B LOINO SURCHARGE <br />APPIICAIION ACC BY PLANSAPPR BY <br />\ ,( �� <br />STATE ENERGY SURCHARGE <br />L5 <br />a) <br />PUBLICWORK9 <br />TOTAL <br />