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/IPPERMIT APPLICATION <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 l 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: 3927 Rucker Ave. Everett,WA 98201 PROPERTY TAX#: 00411300501300 <br /> LEGAL for new construction: Short Plat/subdivision N/A Lot No (attach copy of long legal description) <br /> CONTACT INFORMATION - <br /> OWNER NAME: The Everett Clinic TENANT NAME(If Commercial): Same <br /> OWNER MAILING ADDRESS: STREET 3901 Hoyt Ave. <br /> CITY Everett STATE WA is 98270 <br /> OWNER PHONE: See below OWNER EMAIL: See below2 <br /> CONTRACTOR NAME: N/A Owner-Builder <br /> CONTRACTOR ADDRESS: STREET <br /> cm' S"ATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> PRIMARY CONTACT: 5 OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: Scott Lawson CONTACT PHONE: 425-259-1162 <br /> CONTACT EMAIL: slawson@everettclinic.com <br /> BUILDING PERMIT APPLICATION <br /> Existing Use of Building; Medical Contract Price of Work:$ 120,000.00 <br /> Proposed Use of Building: Medical(no change in use) Heat Source: ElGas Electric ❑Other <br /> Building Type: ❑SFR-Detached ❑SFR-Attached ❑Duplex ❑Multi-Family-#of Units: ®Commercial ❑Industrial <br /> Type of Project: Cl New ❑Addition CI Remodel ❑Repair MT.!. CI Sign CI Sprinkler ODemolition ❑Change of Use <br /> DESCRIPTION OF WORK: <br /> Tenant improvement to existing Walk In Clinic space. Scope of work shall include demolition of reception/staff work area,clinical <br /> utility work room&offices,and the addition of new reception staff work area,clinical utility work rooms,staff work pod and exam <br /> room. There is no change in use or area. <br /> ASSOCIATED BUILDING PERMIT#(if applicable): N/A <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 1 INo.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.•.ore b='': - • zed under any c' I am the owner,or I am authorized by the owner of this property to perform the work for which application is made, <br /> and I corn. : tate ,.rectors Law 18. 96.200A WAC " <br /> �/ / City of Everett Official Use Only <br /> d��� //r/)� PERMIT#��('p O✓ 024 <br /> OwneriAutho"7frAgent Signature Date -r"/ (Revised 9/23/2016)XV <br /> iD <br />