HomeMy WebLinkAbout19906 53RD AVE NE_BLD962002_2026 CITY OF ARLINGTON BUILDING DEPARTMENT
GAS PIPING TEST AFFIDAVIT
Homeowner ZPAIA E VA,6a
Address Z 7o6, 3/:Z'o AVE. A E. Permit No.
The gas piping system was tested at
!S psi for a total of 60 minutes.
_
WITNESSED BY � / / I
(signature of occupant requesting gas service) (date)
INSTALLED BY '� .. �. ,�- 3 C
(signature of installing gas fitter) (date)
43lease arrange for someone to be present on the date of requested inspection
%,_j provide access for the inspector. The white copy must be mailed upon
completion to: City of Arlington - Building Department
238 N. Olympic
Arlington, WA 98223
Hard Copy - Job Site Pink Copy - Contractor White Copy - Mail
C I T1f OF ARU I NETO"`
CQNR-r RUCT 10N PE RM I T
F IERM I T No-
Owner: EV'ANS, PAN 19906 53RD AVE CIE ARLINGTON 98223
Value of Work: $800.00 Tax D, Phone: 435-2733
Describe fork: GAS CONVERT
Proposed Use: RESIDENTIAL
Legal Description:
Job Address: 19906 53RD AVE NE
Contractor's Mace Type Address License#
COZY HEATING M O. LOX 335 C��-gg +;HI* 2 {��y
�d is L LS'1S'.�
1 P E R M I T F E E S
t Equipment and FixturesNu-ber Fee Total Charge
r ----------------` ------ ---- --- ------------
0O0 BTU FURNACE < 100, 1 $1,�-.25 $13.2S I
WATER HEATER 1 $9. 50 $9.50
i
GAS PIPING 1-5 OUTLETS E $5. 00 $10.00
I
SUBTOTAL...... $32.75
TOTALS Fee
Equipment $.32. 75
Mech Permit $22.00
SIGNATURE:
TOTAL FEE... .......... .. .. $54.75 1 HEREBY CL " FY THAT 1 HAVE
AND EXAMINED THIS APPLICATION aN
t'jAYi�:=tv:5... . . . . ... .. .. . . . .30.0 KNOW THE SAME TO BE TRUE GND COR—
RECT ALL PROVISIONS OF LAWS AND
TOTAL DUE.. .. .. ...... ..... $54.75 OrRDP .DICES GOVERNING THIS TYPEE OF
WORT: 4� LL BE COMP WIT' WHETHER
5P CIF_ED HE Pa L
DATE RECEIPT � -3
D BUILDING OFFICIAL
=- ) D T
CITY OP ARLINGTON
CONSTRUCTION
PERMIT
❑ COMBINATION ❑ BUILDING ❑ MECt1ANICAL ❑ PLUMBING
SIGN PERMIT NO. �)CC),;�,
j OWNER MAIL ADDRESS City ZIP ►I(ONE
P� r� (�t✓1S l��Ll� —S3 —_� Pp-�t. 1.�= +rai��r . rll3�z� �3S— Z-)
ARCIIIIECT OR DESIGNER MAIL ADDRESS City 1► /ITONE
Gt9MR-ORIRACIUR MAIL ADDRESS CITY ZIP
CIIANICAL CONTRACTOR MAIL ADDRESS City ZIP PHONE LICENSE
_C-07—L, L CFI t'�— A ILLA t-tL• j '9�5`LZ-S u 25J-Litt C:'11 Cu 'l H -1 Z.Ln�
PLUMBINGCONTRACIOR MAIL ADDRESS CITY ZIP PRONE LICENSE
3 CLASS OF WORK
Q UNLW ❑ADDITION ❑ALTE RAT ION ❑REPAIR ❑DEMOLIIION BUILDING RELOCATION
VALUAIIONOF WORK
s
OLSCRIBE WORK
to ►RUPUSI O USE Of BUILDING
I I IEREBY CERTIFY THAT I IIAVE READ AND EXAMINED THIS APPLICA-
II 1 TuY�iL TION AND KNOW I IF SAME TO BE TRUE AND CORRECT ALL PROVI-
j L,nt ) Sf,RIP1IUN UI PRUPE R 1Y SHOWN BELOW_ OR Al IACII I Ul1R COMES SIONS OF LAWS AND ORDINANCES GOVERNING TI IIS TYPE OF WORK
LUI BLLX K • Of WILL BE COMPLIED WIT I WI IETHER SPECIFIED HERIN OR NOT,It-IF
a GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE AUTHORITY TO
VIOLATE OR CANCEL THE PROVISIONS OF ANY OTHER STATE OR
TAX ID NUMBER PFToM PRoPERTY TAX STATEMENT LOCAL LAW REGULATING CONSTRUCTION OF THE PERFORMANCE OF
: l6�tcl p _ Z-3 j (' �_ CONSTRUCTION.PERMIT EXPIRES 1 YEAR FROM DATE OF ISSUANCE.
LOB AUOR S. SK)NAIURE OF CON1 1 RIZED AGENT DATE
x - --1�F ��l✓
—
PLUMOINO ASCHANICAL
NO. TYPB OF PIXTURS Fab i t FIXTURES NO. TYPE OF EQUIPMENT FBB el FIXTURES
ATER CL.OSITT(TOILET) 37.00 IR COND.UN173-Ill. BA. u1 .Bt•r
AIlITUB $7.00 ISPRIGERATIOH UNITS-112.EA. li .Bt'•
VATORY ASII BASIN $1.00 OILERS-II.P.BAT, uI ."A"
IIOWBR 11.00 IAB FIRED A.C.UNITS-TONNAOEBA. Li .Bt"
TCIIIIN SINKR DISPOSAL 17.00 ORCED AIR SYSTEMS-B.T.U."1S K MRA 1l.00
ISILWASIIBR 17.00 ALL IIELATBR9-B.T.U. M sp."UNDRY TRAY 17.00 NIT ILEATBRS-H.T.U. M E11.00
L0711B9 WASHER $1.00 COOLERSVAPORATIVE
AlgR ISBATER $7.00 'LOT11tS DRYERS fi30
RINAL $7.00 ERNTIIATION FAN 1431
RINILINO FOUNTAIN $7.00 LANOE IIOOD COMMERCIAL, $630
ILOOR DRAIN 0." IR HANDLING UNIT- CPM
ACUUM BREAKURS ST." VB 1630
OOP DRAINS-RAINL.EIADERS $7.00 ETAL PIREPLACH A CIIIMNBY 1630
IN[ SERVICE-BAR THU. 17.00 ATER IIBATFR 31130
2— _ AS PIPINO '(UP to S-17.00.addol. 1.75
'PyulpmeuL Iltl must ba ptovlded
SUB TOTAL SUB TOTAL
PERMIT PERMIT
TOTAL PEB TOTAL PEE
SIDL YARdS IBACK 1IRL ISIIBACK REAR VARb5E16ACk PLANCIIECK NUMBER PLAN CIIECK F E
FEE RECEIPT NO.
USF /UNI LOT ARf..A VACANT SITE
[]YES []No FEES VALUATION FEE
IYPLOI CONSI- OCCUPANCY GROUP NO.OF DWELLING UNI IS PLAN CHECKING VG
SI/.E DI BlU<., NO.OT SIURII,S MAX.UCC.LOAD
BUILDING 1
PLUMBING
I IRE SPRINKLERS REQUIRED
u YES ❑NO MECIIANICAL
COMMENTS STATE BLDO.CODE
ENERGY CODE SURCHARGE
u.e.c
PENALTY SEC.30lI21 I
WATER/SEWER FEES
TOTAL
PERMIT VALIDATION
WI IEN PROPERLY VALIDATED IIN TI IIS SPACEI THIS IS YOUR PERMIT b RECEIPT
PAID CRN BY
cc!ASSESSOR,APPLICANT.TREASURER. BLDG. DEPT. BUILDINGOFfICIAL DATE
TTECOTTDS COPY