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TM EwrgraR `-APPLICATION FW 4«TYOF CONSTRUCTION <br />everett PERMIT <br />TO BE COMPLETED IN BLACK INK- PLEASE PRINT <br />BUILDING DEPT. <br />259.8745 <br />❑ COMBINATION ® <br />BUILDING ❑ <br />MECHANICAL ❑ PLUMBING ❑ SIGN <br />OWNER <br />MAIL ADDRESS <br />CIT <br />SIP INTONE <br />J�;FI CiR_r1+y <br />291,9 C0/Gv 4✓e, <br />A.�veRGn <br />F.vy gfil'/ .TS.z •SS'9S' <br />ARCHI QC T ON DESIGNER <br />MAR ADOnE9 <br />CTTY <br />SIP PHONE <br />DINE PAL CON I PACT On <br />PHONE <br />PNIGNE <br />F OB <br />PLUMBING CONTRACTOR MAIL ADDRESS CITY SIP PRONE LICENSE IT <br />r.I ASS O! WORK <br />NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ DEMOLITION ❑ WOODSTOVEIFRPL.INSERT ❑ BUILDING RELOCATION <br />VALUATION OF WOnK ICOSI or MAf r LIAI.S PLUS t6jr%. <br />OESCnIBE WORK <br />/7... %% 7 /7r.lAYFOM /'/CM U <br />USE or BUII 0410 <br />iA ,ve/-c ;A1 / �V <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS AP• <br />PLICATIONAND KNOWTHESAMETOBETRUEANDCORRECT.ALL <br />PROVISIONSOF LAWSAND ORDINANCES OOVERNINOTHIS TYPE <br />OF WORK WILL BE COMPLETED WITH WHETHER SPECIFIED HERE - <br />INORNOT, THE GRANTING OF A PERMIT DOES NOT PRESUME 70 <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 C04TAACTOR OR AUTHORIZED AGENT DATE <br />X <br />LEGAL DESI:PIPUONOFPROPERTYISu0WN0 OWORATTACHFO COPIES <br />LOT / 9LOCK_0F -W / d <br />PROJECT ADDRESS <br />, A / 3 / —'I 7-r SJ e <br />APPLICA TS CITY BURIN SLICE SE NO <br />PLUMBING <br />MECHANICAL <br />NO. <br />TYPE OF FIXTURE <br />FE <br />NO. <br />TYPE OF EQUIPMENT <br />FEE <br />WATER CLOSET (TOILET) <br />AIR COND. UNITS-H.P. EA <br />BATHTUB <br />0 <br />REFRIGERATION UNITS-H.P. EA. <br />LAVATORY IWASH BASIN <br />QQ <br />BOILERS-H.P. EA. <br />SHOWER <br />00 <br />GAS FIRED AC. UNITS-IONNAOE EA <br />L <br />FITCHEN SINK& DISP. <br />.Z <br />OO <br />FORCED AIR SYSTEMS-B.T.U. M EA <br />DISHWASHER <br />v2 <br />VT- <br />WALL HEATERS-B.T.U. M u,0, <br />IF <br />LAUNDRYTAAY <br />D <br />UNIT HEATERS-Bi.U. M <br />_ <br />CLOTHES WASHER <br />7 <br />0 <br />EVAPORATIVE COOLERS <br />i <br />WATER HEATER <br />�_ <br />CLOTHES DRYERS <br />_ <br />_j <br />URINAL <br />VENTILATION FAN <br />_ <br />DRINKING FOUNTAIN <br />FLOOR DRAIN <br />RANGE IIOOD <br />AIR HANDLING UNIT- C.F.M. <br />E/ _ <br />VACUUM BREAKERS <br />STOVE <br />_ <br />ROOF DRAINS-RAINLEADERS <br />METAL FIREPLACE & CHIMNEY <br />_ <br />SINK SERVICE -BAR, ETC <br />WOODSTOVE/FIREPLACE INSERT <br />SUB TOTAL <br />SUB TOTAL f <br />PERMIT <br />0� <br />_ <br />PERMIT • <br />TOTAL FEE • <br />TOTAL FEE t <br />S <br />D <br />THIS PORTION TO BE COMPLETED BY BUILDING DEPT. PERSONNEL <br />I PORT SEIIIACK <br />/ <br />FILAR SETBACK <br />/ <br />SIDE SETBACK <br />,PLAN Mnc nvvovl <br />^' <br />—.1-11. <br />17 Q <br />— <br />.7 7 <br />FIT'.11 <br />RECEIPT NO <br />USL IONE <br />LOI AREA <br />VACANT SIIE <br />AES ONO <br />FEES <br />VALUATION <br />FEE <br />TYI'E OF CONST. <br />OCCUPANCY GROUP <br />NO OF DWELLIIO UNITS <br />�' 3 <br />_Y'/�/ <br />BUILDING <br />t <br />pJ <br />• jI E Of NMO/PINO OF STORIES MAX OCC. LOAD <br />/y411a / <br />PLUMBING <br />C� <br />MECHANICAL <br />x <br />Q <br />FIRE SPRINKLERS REQUIRED I]YES ❑ NO <br />OTHER <br />PENALTY <br />APPLICATION ACC BY <br />PLANSCIIECKEDBY <br />APPR FOR ISSUANCE BY <br />TOTAL <br />ell) D <br />0 <br />