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PERMIT APPLICATIOM <br /> BUILDING/ MECHANICAL/ PLUMBING /SIGN /SPRINKLER/ DEMOLITION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: tg 03 112 1'V1 . 65 (✓•uc..m... --1/4A ci°67142SERTY TAX#: <br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: TENANT NAME(If Commercial): 13G nuc a ATYk.Ar 1 Ge <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: 14,k+c,n't- Comp —rVt <br /> CONTRACTOR ADDRESS: STREET iU o9 face,(QiG }�W e. If, 1 <br /> CITY c-j cr.L, STATE W A ZIP `f t•Lt 2 <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LICENSE#(REQUIRED): Lp0,( p CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR OTHER(Please Specify) A rc.Ank Cdr. <br /> CONTACT NAME: q i 1s5G (1:,tt,,.7 CONTACT PHONE: 20. LtO _ 5�(j� <br /> �+4 W t� CONTACT EMAIL: yy(,Vo llea,c,o ise,r tOYt vlej f)c YVt <br /> BUILDING PERMIT APPLICATION <br /> Existing Use of Building: ` ,1,5cY ,c-,c> / t;t,h k Contract Price of Work:$ FSO) 0-176 <br /> Proposed Use of Building: ' jamfl..11 Heat Source: ❑Gas ❑Electric Other <br /> Building Type: ❑SFR-Detached EISFIR-Attached ❑Duplex��Multi-Family-#of Units: Commercial ❑Industrial <br /> Type of Project: ❑New ❑Addition ❑Remodel ❑Repair L9T.I. ❑Sign OSprinkler ❑Demolition ❑Change of Use <br /> DESCRIPTION OF WORK: <br /> ASSOCIATED BUILDING PERMIT#(if applicable): • <br /> MECHANICAL PERMIT APPLICATION PLUMBING PERMIT APPLICATION <br /> Type of Project: _New_ Addn _Alteration _Repair Type of Project: _New _Addn _Alteration _Repair <br /> #of List of Fixtures #of List of Fixtures #of List of Fixtures #of List of Fixtures <br /> Fixtures Fixtures Fixtures Fixtures <br /> NC—Air Handling Units Heat Pump Toilet Backflow Preventer(Inside Bldg) <br /> Forced Air Systems Unit Heater Bathtub Urinal <br /> Gas Piping Boiler Lavatory(Wash Basin) Drinking Fountain <br /> Water Heater Refrigeration Shower Floor Drain <br /> Gas Fireplace Wood Stove Kitchen Sink&Disposal Grease Trap <br /> Gas Range Ducting Dishwasher Roof Drains <br /> Clothes Dryer Hookups Other: Clothes Washer Medical Gas <br /> Range Hood Water Heater Other: <br /> Exhaust Fan Sink(Service/Bar/Mop/etc.) Other: <br /> SPRINKLER/SUPPRESSION SYSTEM <br /> Chemical or Water No. of Heads • <br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must comply with <br /> current federal,state,and local law.The granting of a permit only authorizes approved work and no deviations therefrom.Deviations must first be authorized in writing from the <br /> Building Official before being authorized under any circumstance.I am the owner,or I am authorized by the owner of this properly to perform the work for which application is made, <br /> and I com ly wi the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> • <br /> �� n ICCPER «U -044 <br /> Owner/Authorized Agent Signature Date (Revised 9/23/2016) <br />