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APPLICATIOi FOR CONSTRUCTON PERMIT <br />TO BE COMPLETED IN BLACK INK --PLEASE PRINT �w <br />BUILDING DEPARTMENT <br />HEATING SYSTEM: ❑ GAS ❑ ELECTRIC ❑ ___ _ _ <br />— <br />259-8810 <br />DEMOLITION COMBINATION I BUILDING J MECHANICAL I PLUMBING ja <br />.....,...,a "m ZIP PHONE <br />tENANE MAILADDPEss Cm ZIP Rf.7l <br />_SW As A46&Ae <br />ARCNIFECT(WIMSGNLR ANA ADDPESS cm ZIP MYIE <br />GENFRALC TFMCTM MAIL ADDRESS CITY ZIP Mrs) <br />STAR LICENSEE <br />S/W S/6✓ �/k5/bv a/S $ { Jr lFXLtAC A G 980PJ 8//�i%'_/dou A/OR NSO0 I 1 <br />.. .-.. .�............e ...x .muccc fJiv ZIP PI"E STAR UCENSEE <br />MgNE <br />CpITRACT INI CE OF W K <br />S� <br />DESCRBE KOPK ANpSWAPE iQITAGE mYRVED <br />1 <br />COMIC' PER DPNCN[NO <br />M1_/Yioi-5/'f t'— G7•S� <br />I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS <br />APPLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT ALL <br />PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE OF <br />WORK WILL BE COMPLETED WITH WHETHER SPECIFIED HEREIN OR <br />NOT. THE GRANTING OF A PERMIT DOES NOT PRFSUME TO GIVE <br />AUTHORITY 10 VIOLATE OR CANCEL THE PROVISIONS OF ANY <br />OTHER STATE OR LOCAL LAW REGULATING CONSTRUCTION OR THE <br />PERFORMANCE OF CONSTRUCTION. THAT I AM AUTHORIZED BY THE <br />OWNER OF THIS PROPLRTY TO PERFORM THE WORK FOR WHICH <br />APPLICATION IS MADE AND I COMPLY WITH THE STATE <br />CONTRACTORS LAW 18.27 CW AND 296.200 WAG <br />PrUSE eu�aP1Nc <br />J/ F�/Il / v <br />L[CAL MWAPI" V PPWERT IBNovm eE MDRATTFCHrwocrolES1 <br />IGT BwOK of <br />— <br />— <br />PARCELTAA ID NU'NEA <br />6oSS-' 'Z-o <br />CWSIPUCTK1N Lo .LENDEP ADDRE%. LEIFPHPYE NVMPFR <br />PROJECT ADDRESS <br />— <br />PLUMBING <br />MECHANICAL <br />NO. TYPE OF EOUIPMENT FEE <br />A0.C—A HNDLG UNITS—H.P. <br />NO. <br />TYPE OF FIXTURE OR ITEM <br />FEE <br />WATER CLOSET (TOILET) <br />BATHTUB <br />FORCED AIR SYSTEMS—B.T.U. M E A. <br />LAVATORY (WASH BASIN) <br />UNIT HEATERS—B.T.U. M <br />SHOWER <br />CLOTHES DRYERS <br />KITCHEN SINK A DISP <br />VENTILATION FAN <br />DISHWASHER <br />RANGE HOOD <br />LAUNDRY TRAY <br />WATER HEATER <br />_ <br />CLOTHES WASHER <br />WOOD STOVE <br />URINAL <br />METAL FIREPLACE (WOOD BURNING) <br />DRINKING FOUNTAIN <br />FIREPLACE INSERT <br />—� <br />FLOOR DRAIN <br />HEAT P UMP <br />BACKFLOW PREVENTERS <br />GAS PIPING <br />ROOF DRAINS—RAINLEADEHS <br />EXHAUSTFAN <br />SINK (SERVICE —BAR. ETC.) <br />E <br />SUBTOTAL $ <br />SUBTOTAL S <br />PERMIT $ <br />PERMIT f <br />TOTAL FEE S <br />TOTAL FEE $ <br />P(1R AFFIOR OSF ANI Ye <br />i1pNT SETBACK REARSETBACK <br />SNE SETBACK <br />IYAN CHECK NUMBERO <br />FEE 20 <br />PECEIPTW <br />USE ZONE <br />- <br />.GT AREA <br />VACANT EIR <br />❑ YES I-] NO <br />FEES <br />VALUATION <br />FEE <br />BUILDING <br />��''ll <br />W <br />rmaca+sr <br />ND asro+.Es <br />0 <br />wouHU�kw.,E <br />PLUMBING <br />SIZEo`BLDD. <br />FIRESPRmKLERSPEOD <br />BASEMENT <br />❑ YES Cl NO <br />MECHANICAL <br />ADDITKMAL PLAN CHECK <br />OCCUPANCY LOAD <br />FIREAARMPEGD <br />WKAITLMRABDN <br />OTHER <br />REASDN <br />mrrxE By PLAN. ypl ro- CITY OF EVERETT <br />LOCAL SALES <br />11,y �, TAX CODE IS 3105 <br />STATE BUILDING SURCHARGE <br />I Zj <br />PuBuc wglKs <br />TOTAL <br />, <br />92 ; �j <br />