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APPIACATIGN FoR S�PY--PEPII <br /> �nof` "A CCiNSTRUCTION Ip� <br /> everett PERMIT <br /> TO BE COMPLETED IN BLACK INK–PLEASE PRINT <br /> BUILDING DEPT. <br /> 259.8745 ❑ COMBINATION ❑ BUILDING ❑ MECHANIUAL ❑ PLUM TING I] SIGN <br /> OWNER MAIL ADDRESS CITY IIP PHONE <br /> S�OMVIDh G� yS- l�' tIEAuAlwtz 9 or-o l4 <br /> RCNIIECT OA OT.BIGNER MAIL ADDRESS CITY ZIP PrIONC <br /> OENEHALCONTRACTOF MAIL AGGRESS CITUTY ZIP IIP PHONE LCENSLA <br /> MECHANICAL CONTRACTOR MAIL ADORES) CITY ZIP PHONE LICENSEE <br /> v.VMBINO COIQ,UGIORMAIL AODRE55 CITY IIP PHONE IKGNSEF <br /> CLASS OF WORK <br /> NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVE/FRPL.INSERT ❑ BUILDING RELOCATION <br /> VALUATION Of RKICOST OF MATERIALS PLUS LABOR) �y{� <br /> O <br /> DESCRIBE.WORK i <br /> �tcl_ In <br /> USEOF BUILDING I HEREBY CERTIFY TH,%T I HAVE READ AND EXAMINED THIS AP- <br /> PLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT.ALL <br /> LEGAL DESCRIPTION OF PROPERTY ISIIOWN UcLOa GH ATTACH FOUR COMESI PROVISIONS OF LAWSAND ORDINANCES GOVERNING THIS TYPE 1 T <br /> OF WORK WILL BE COMPLETED WITH WHETHER SPECIFIED HERE- <br /> LOT DLOCK—GF IN OR NOT.THE GRANTING OF A PERMIT DOES NOT PRESUME TO Ini <br /> GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OK r) <br /> C ANY OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION c v <br /> OR THE PERFO E 0 CONSTRUCTION. m o <br /> n <br /> Ct D 810NnTU E Of coT i R O T110RRED AGENT DATE <br /> — ,O m z <br /> PROJECT ADDRESS v ao� _ 0 �vv AP LI'A T CITY tlU NESS Ir ,NSE NO Q Z <br /> D <br /> PLUMBING MECHANICAL <br /> NO. TYPE OF FIXTURE _ FE NO. TYPE OF EQUIPMENT FEE K <br /> 0 <br /> IV WATER CLOSETITOILET) 00 AIR COND.UNITS-IL P.EA ITy <br /> BATHTUB REFRIGERATION UNITS-H P.EA __ 3 <br /> LAVATORY1WASH BAST _ CO BOILERS-H.P.EA. rn <br /> = m <br /> SHOWER co GAS FIRED AC,UNITS-TONNAGE EA 0 In <br /> KITCHEN SINK&DISK _ ` 00 FORCED AIR SYSTEMS-B.T.U. MEA. <br /> DISHWASHER Wrl <br /> HEATERS-B.T.U. M Q 3 <br /> LAUNDRYTRAV UNIT HEATERS-ST.U. M Q Fn N <br /> CLOTHES WASHER Z OD EVAPORATIVE COOLERS <br /> WATER HEATER �11 _ CLOTHES DRYERS D <br /> URINAL VENTILATION FAN 3L 7O <br /> DRINKING FOUNTAIN RANGE HOOD --/ <br /> FLOOR DRAIN AIR HANDLING UNIT- C.F.M. _ <br /> D <br /> VACUUM BREAKERS STOVE z <br /> ROOF DRAINS-RAINLEADERS METAL FIREPLACE&CHIMNEY <br /> WOODSTOVE/FIREPLACE INSERT S <br /> tr <br /> 81NN SERVICE-BAR ETC) -� <br /> 4) <br /> O <br /> �-1 <br /> N <br /> C ) <br /> SUBTOTAL <br /> SUBTOTAL t <br /> PERMIT t PERMIT • <br /> _ TOTAL FEE t _ TOTAL FEE t _ <br /> THIS PORTION TO BE COMPLETED BY BUILDING DEPT. PERSONNEL <br /> FRONT SETBACK <br /> REAR SETBACK SIDE SETBACK PLAN <br /> PLAN CHECK-NUMBER ^ 3�,PLAN CHECyK1yFEF <br /> &fr/—aY/ IA I Qd� FEE/uL REG <br /> USEZONE LOT AREA VACAyT SITE 1 FEES VALUATION FEE <br /> /7 , / =1 ONO <br /> TYPE OF CONST OCCUPANCY GROUP NO OF OW EL L ING UNITS — <br /> V-N ps i M I JUUDING�9_0� 00 <br /> j OF BLOC NO OF STORIES MAX OCL LOAD <br /> /C3 PLUMBING (ro <br /> _ o S•' <br /> MECHANICAL <br /> FIRE SPRINKLERS REQUIRED D YES O NO OTHER <br /> PENALTY <br /> APPLICATIONACC BY PLANS CHECKED BY APPR FOR ISSUANCE By n� <br /> TOTAL J <br />