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PiPPLICATION FOri PYP,PN <br />o "" <br />C.T(OF CONSTRUCTION <br />'1, <br />everett PERMIT <br />BUILDING DEPARTMENT <br />TO BE COMPLETED IN INK- PLEASE PRINT <br />❑ DEMOLITION CI COMBINATION ❑ BUILDING ❑ MECHANICAL ❑ PLUMBING O SIGN <br />nwuUl -- MAIL ADDRCNS Crtv Lr IOIONE <br />{�O(�oTt 592 /./i L—e i82r8 GSJ <br />AIILluR 1. I On DI ci wo MAIL ADDRESS CITY bn PHONE <br />ULNL IIAL CONIIMCIO'I MAIL ADDRESS CRY ZIP PHONE IICEgSr• p <br />........... CIEY ZIP PHONE LICENSE <br />PIUMDnni CONIPACION MAIL ADDRESS CITY ZIP %ZONE LICE IISE• <br />CL AtS OF WOI+M <br />LYj ryEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ DEMOLITION 171 WCODSTOVE/FRPL.INSERt ❑ BUILDING RELOCATION_ <br />VAI LIATION OF WORK ICOST or MATERIALS PLUS LABORI <br />le <br />[IL Sl: P111E WUIIK <br />I✓EC[J <br />ONE. IF, <br />. t /I/ !/ e <br />Ll OAL OF Nl m-InnF+n .'n <br />Lol DLICrqA <br />,15OI: % <br />PRDIr CT ADDI+:1 S <br />lie <br />I HEREBY CERTIFY THAT 1 HAVE READ AND EXAMINED THIS AP- <br />PLICATION AND KNOWTHE SAME TO BETRUE AND CORRFCT. ALL <br />PROVISIONS OF LAW3AND ORDINANCES GOVERNING TI ITS TYPE <br />OF WORK WILL BE COMPLEIED WITH WHETHER SPECIFIED HERE- <br />IN OR NOT. THEGRANTING 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 THE PERFORMANCE OF CONSTRUCTION. <br />SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT DATE <br />X <br />MECHANICAL <br />PLUMBING <br />FEE <br />NO. <br />TYPE OF EQUIPMENT _ <br />FEE <br />RIC. <br />TYPE OF FIXTURE <br />WATER CLOSET TOILET) <br />O <br />AIR COND. UNITS-H.P. EA _ <br />_ <br />_� <br />REFRIGERATION UNITE-N.P. EA. <br />_ <br />p. <br />BOILERS-N.P. EA <br />_BAINTUB <br />LAVATORY (WAS" BASINI <br />— <br />OAS FIRED AO UNITS -TONNAGE EA <br />SHOWER <br />FORCED AIR SYSTEMS-B.T.U. M EA. <br />_ <br />KITCHEN SINK DISP. _ <br />WALL HEATERS-B.T.U. M <br />DISHWASHER <br />UNIT HEATERS-B.T.U. M <br />_ <br />-7 <br />LAUNDRY TRAY <br />CLOIII ES WASHER <br />EVAPORS <br />-- <br />ORYEOOIERS <br />CLOTHES DRYER9 <br />�� <br />-- <br />VENTILATION FAN en✓ <br />�i <br />`J <br />URINAL <br />RANGE HOOD <br />DRINKING FOUNTAIN <br />AIR HANDLING UNIT- CF.M. <br />FLOOR DRAIN <br />VACUUM BREAKERS <br />STOVE <br />METAL FIREPLACE A CHIMNEY <br />ROOF DNAINS-RAINLEADERS <br />WOODSTOVE/FIREPLACE INSERT <br />_ <br />SINK SERVICE -BAR, ETC <br />'•"1 - <br />'r7_ <br />3 <br />SUB TOTAL • <br />SUB TOTAL <br />O <br />PERMIT • <br />• <br />PERMIT <br />TOTAL FEE • <br />`/ 7- <br />TOTAL FEE -_ • <br />----- <br />THIS PORTION TO BE COMPLETED BY BUILDING DEPT. PERSONNEL <br />