12800 19TH AVE SE 2019-11-15 - Laserfiche WebLink

MIN PERMIT APPLICATION 12. BUILDING/ MECHANICAL/ PLUMBING / SIGN /SPRINKLER / DEMOLITION E V E R E T TCITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT,WA 98201 WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits (Blue or Black Ink Only Please) PROJECT SITE INFORMATION PROJECT SITE ADDRESS:12800 BCthall Eiz tt Hwy `6(.. , AOc ye SE----- PROPERTY TAX#:28053000407200 LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description) CONTACT INFORMATION OWNER NAME: Providence Health and Services TENANT BUSINESS NAME(Commercial): OWNER MAILING ADDRESS: STREET 1321 Colby Ave cin. Everett STATE WA ZIP 98201 OWNER PHONE: 425- - 19 OWNER EMAIL:lames.grafton@providence.org CONTRACTOR NAM :TBD V J/ 1 ' If,j 1 CONTRACTOR ADDRESS: STREET D gi0X I-J1_. CITY bY}ft STATE InriA_ ZIP iq 6'Loco CONTRACTOR PHONE: f� CONTRACTOR EMAIL: CONTRACTOR LICENSE#(REQUIRED):J D 0 IAA,1 10 Li �� CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): on 6,(4 rQ PRIMARY CONTACT: D OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE:425-218-0919 James Grafton CONTACT EMAIL:james.grafton@providence.org BUILDING INFORMATION Existing Use of Building:Medical Clinic Contract Price of Work: $39,000 Proposed Use of Building:Medical Clinic Heat Source: OGas DElectric ❑Other BUILDING USE: ❑SFR ❑Townhouse Duplex ❑ADU ❑Multi-Family-#Units: ❑✓Commercial ❑Accessory Structure Type of Project: ❑New Addition ✓❑Remodel Repair T.I.❑ ❑Sign Sprinkler ❑Demolition ❑Change of Use DESCRIPTION OF WORK: Addition of partitions and doors to separate office areas and break room from clinic hallways. ASSOCIATED BUILDING PERMIT#(if applicable): MECHANICAL PERMIT APPLICATION PLUMBING PERMIT APPLICATION Fixture Fixture Fixture Fixture Count List of Fixtures Count List of Fixtures Count List of Fixtures Count List of Fixtures A/C—Air Handling Units Gas Piping Backflow Preventer(Inside Bldg) Shower,Tub,or Combo Boiler Gas Range Clothes Washer Sink-Commercial(3-comp,prep,floor) Clothes Dryer Heat Pump&Ductless Dishwasher Sink-Residential(kitchen,bath,bar) Duct System(Remodel) Refrigeration Drinking Fountain Sink-Utility,laundry,mop Exhaust Fans(Residential) Commercial Ventilation Floor Drain Toilet Exhaust Hood(Type I) (Not Heat/AC system) Hose Bibb Urinal Exhaust Hood(Type II) Water Heater Interceptor-Grease Waste/Water Piping Repair Exhaust Hood(Residential) Wood Stove Interceptor-Sand/Oil Water Service(behind meter) Forced Air Systems Other: Medical Gas Water Valves or Fixtures Gas Fireplace/Insert/Log Roof Drains Water Heater SPRINKLER/SUPPRESSION SYSTEM Sewage Ejector or Sump Pump Other: Water Suppression System No.of Heads Chemical Suppression System No.of Heads 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 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 Building Official before being authorized under any circumstance.I am the owner,or I am authorized by the owner of this property to perform the work for which application is made, and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. 1 City of Everett OfficialUseOnly ,00, . ; ' '7�''e/ PER \ 1 64— on l 5 ":, er/Authorized Agent Signature Date (Revised 10/10/2018)