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-CONSTRUCTION <br />PERMIT APPLICATION 312- 6' 7 <br />COMBINATION • BUILDING • MECHANICAL • PLUMBING <br />OWNER MAIL AOUHkSS <br />ZIP PHONE <br />plf�� p AS �c <br />f3oK (cID-7 L1g pu <br />ARCHITECT ON DESIGNER [/ MAIL ADDRESS <br />—LICENSE NU it <br />IHONE " <br />4 <br />10, <br />GENLRALCON TRACTOR MAIL AGDPESS <br />11 <br />PHONE, LICENSE NU. <br />1 / l/ <br />MECHANICAL CONTRACTOR MAIL ADDRESS <br />PHONE LICENSE NO. <br />+� <br />0f4-*__*" ly 1W&_)ol"/ 1� <br />PLUMBING CONTRACTOR MAIL ADDRESS <br />PHONE LICENSE NU. <br />lam S '404i' Y7 lS/ �L <br />, <br />- <br />vkq CL ASS Oi WORK <br />CO BIN ATION <br />UILDING IUMBI N6r MECHANICAL <br />❑HLPn111 <br />NW <br />❑ADOITIUN L]ALTEIIA nUN <br />VALUATION OF W RK <br />�— ❑DEMOLISM <br />❑FENCE ❑SIGN ❑':)Y I•.IMIN[) 1•[)OI., <br />s <br />-� <br />DESCRIBE WORK ,/ '• , �A �,. <br />OTHER PERMITS OR APPROVALS <br />PROPOSED USE <br />REZONE t( SPECIAL USE <br />l LOAL UkSCR IPTION OF PROPk RTY ISHOW OE LDW OR ATTACH <br />FOUR COPIL51 �.g tiT•G� <br />#VARIANCE .y SF'.ORLINE <br />LOT BLOCK —OF-- <br />_BLOCK <br />SEPA CHECK LIST EOUIRED <br />�YES <br />NO <br />JOB ADDRESS <br />_ y/j <br />MECHANICAL <br />TYPE OF ENERGY ❑Ii AS ❑F LE C. <br />PLUMBING <br />NO. TYPE OF F.OUIPMENT FfE <br />AIR COMO. UNINITS—H.P. CA_ _—r <br />NO. TYPE OF FIXTURE OR ITEM FEE <br />REF R IGERnT ION UNu!. LIP LA. <br />1 <br />BA1H TIrD <br />1 <br />BOILERS Ho LA. _ -_T— <br />II.T.D A. <br />CLOTHES WASHER <br />fURCED AIR SYSTEMS _ME <br />DISII WASHEIIS`- <br />17111NKING FOUNTAINS <br />SPACE FWALL HEATERS -O.T.U. ___L--- <br />FLDOH BRAINS �- <br />UNIT HEATERS—_N. T.U. <br />KI11'IIF.N SINKS I, la �� <br />_ <br />EVAPORATIVE COOLERS J_ <br />LIAR SINKS T— <br />IIUOF DRAINS MAIN ICAOE <br />_ <br />CLOtllkB DRYE <br />SHOWER BATHS <br />VENTILATION FAN <br />1 <br />TiERVICE SINY.S <br />RANGE 1/ODD _ <br />�— --- —T <br />SUMPS SEWAGE PU P <br />_ <br />AIR I/ANDLINGUNIT C,I.M. .. •,__,•,_y - _ <br />- - _.. <br />UIIINALS.-T-.— <br />- .•_ <br />WAIEll CLOSETS <br />_WATER HEATER_ _-..L_—..- <br />Wi(TLH IILATERS ELECT HIC 1 <br />. _ _. _. .. .. <br />FAC. BUILT FIREPLACE A CHIMN_f_Y <br />_ <br />WASTE BASINS - I <br />GAS. SYSTEM: NO OF OU TLI IS I � <br />;� <br />U111UTAL_S <br />^� <br />I <br />"-----•--�__-_ ---TOTAL FkE_S 1!A� <br />i <br />SUD TOTAL <br />11115 Pt 111,11T OECGM ES NDI l ANY) VOID It W1111K OR CONSTRUE <br />PERMITf <br />__ .E <br />TION AU IIIa RIZED IS NOT C(IMML NCIO WITHIN 1?D UAVS. OR IF <br />NOED n11 AIIANDONED FOR A <br />---' <br />CONSTHOCTION OR WORK 11: SUI:PI <br />PLRIOD OI 170 DAYS AT ANY TIMI At IEII WOHK I!: COMMk NCLD. <br />WATER SERVICE S12F. BLDG. SUPPLY BI7.E <br />I III. RLIiv CERTIFY THAT I IIAVE RLAI) ANC, EXAMINE TINS AP <br />SETBACK HEAR VAHU St TBACK PLICAT ION AND KNOW THE. SAME TO Ilk TRUE AND C(11)IITC r. ALL <br />ORDINANCES GOVERNING T1415 TYPE <br />PROVISIONS OF 1 AWS AND <br />ACOMPLIED Wit" To FIER HEREIN <br />NOT PRESUME TO <br />Ulil 7t1NE LOT ARIA V%�CANf filTk <br />A <br />N.T TO NCE o VIOLATE ON PERMIT <br />OR NOT. Tilt GRAN;IN6 OF A PERMIT DOES <br />OWE T. Og GRLL <br />0CANCL LE THEE RI (IV 41q NS <br />I7 J_— ❑YES ❑NO <br />I ANY OTHER ST E On LUCAI lAW ME LA :O IWCTION <br />►LgFO*ANC FCONSTj 1FON r <br />/�•�L <br />T TYPE U/ CO NST. CCUPANL°Y GROUP No. OF OWkIIING <br />ORTHk <br />/ <br />UNITS /J <br />612E O� BLOC. No.O STORLLS MAX. BCC. IOAO <br />i ,' <br />-• <br />¢� Q� <br />SIGNAT EOFCONTRAC70 RAUT I1. AOk NY TE <br />I )1/k LflNk IlA::!=iQNt I IIIL 41'HINRII <br />REUUIIH I) <br />lnN CHECK NUMBER PLAN CIIL- 4kt <br />A''l� <br />y � ❑YFS BAD <br />1 LE RECEIPT NH <br />SPECIAL CONOITIONS: <br />VALUATION — FEE <br />_ I <br />BUILDING <br />SEPA REVIEW COMPLETE : OYES ❑ NO <br />pLum"INII <br />---- - L� <br />MECHANICAL <br />Contact Dlannlnq dept. <br />I <br />OTI/L'P ) <br />wrrlIU1NN PN.IHIy Y• wILa1Y YY ArPPBY1R UN ILWwKI i <br />1 <br />Y PENALTY SEC. 2071F1 <br />1 <br />T <br />TOTAL <br />