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PERMIT APPLICATION <br /> �/— BUILDING/MECHANICAL/ PLUMBING I SIGN I 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 www.everettwa.govipermits <br /> (Blue or.Mack.Ink OlnlyPIease)' ::.::...: ..:::PROJECT.SITE INFORMATION .. : ::.,.. ... .. .. <br /> PROJECT SITE ADDRESS: 1434 GRAND AVE PROPERTY TAX#: 00475331100006 <br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description) <br /> CONTACT.INFORMATiON <br /> • <br /> OWNER NAME: CLINTON SIEDENBURG TENANT BUSINESS NAME(Commercial): <br /> OWNER MAILING ADDRESS: STREET 1434 GRAND AVE <br /> CITY EVERETT STATE WA ZIP 98201 <br /> OWNER PHONE: 425-257-1362 OWNER EMAIL:CLINTON.SIEDENBURG@FRONTIER.COM <br /> CONTRACTOR NAME:GS HEATING <br /> CONTRACTOR ADDRESS: STREET 3409 EVERETT AVE <br /> cry EVERETT STATE WA ZIP 98201 <br /> CONTRACTOR PHONE:425-610-4257 CONTRACTOR EMAIL:MELANIE@GSHEATING.COM <br /> CONTRACTOR LICENSE#(REQUIRED):GSHEAHC821 QR CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 60058 <br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE:425-.610-4257 <br /> MELANIE MENDENHALL CONTACT EMAIL:MELANIE@GSHEATING.COM <br /> BUILDING INFORMATION <br /> Existing Use of Building:RESIDENTAIL Contract Price of Work: i ('i 6• ? <br /> Proposed Use of Building:RESIDENTAIL Heat Source: ❑Gas ❑Electric ❑Other <br /> BUILDING USE: OSFR ETownhouse ❑Duplex EIADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> Type of Project: ❑New DAddition ❑,r Remodel DRepair ❑T.l. ❑Sign ❑Sprinkler ❑Demolition ❑Change of Use <br /> DESCRIPTION OF WORK: INSTALLATION OF HEAT PUMP <br /> ASSOCIATED BUILDING PERMIT#(if applicable): <br /> MECHANICAL PERMIT APPLICATION PLUMBING PERMIT APPLICATION <br /> Fixture Fixture Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures Count List of Fixtures Count List of Fixtures <br /> A/C--Air Handling Units Gas Piping Backflow Preventer(Inside Bldg) Shower,Tub,or Combo <br /> Boiler Gas Range Clothes Washer Sink-Commercial(3-comp,prep,floor) <br /> Clothes Dryer i Heat Pump&Ductless Dishwasher Sink-Residential(kitchen,bath,bar) <br /> Duct System(Remodel) Refrigeration Drinking Fountain Sink-Utility,laundry,mop <br /> Exhaust Fans(Residential) Commercial Ventilatior Floor Drain Toilet <br /> Exhaust Hood(Type I) (Not Heat/AC system) Hose Bibb Urinal <br /> Exhaust Hood(Type Ii) Water Heater Interceptor-Grease WasteMfater Piping Repair <br /> Exhaust Hood(Residential) Wood Stove Interceptor-SandiOil Water Service(behind meter) <br /> Forced Air Systems Other. • Medical Gas Water Valves or Fixtures <br /> Gas Fireplace/Insert/Log Roof Drains Water Heater <br /> SPRINKLER./SUPPRESSION SYSTEM Sewage Ejector or Sump Pump Other <br /> Water Suppression System No.of Heads <br /> Chemical Suppression System No.of Heads <br /> ACKNOWLEDGEMENT.1 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 1 am authorized by the owner of this property to perform the work for which application is made, <br /> and I comply with the State Contractors Law 18.27 RCW and 296.2004 WAC. <br /> City of Everett Official Use Only <br /> t <br /> ) t .(i 1/V -e/tiCAA/vv t "."- <br /> " 'f toil ' `O} PERm#� \G 0 _ 029 <br /> OwneriAutho Iz d Agent Signature Date (Revised 10/10/2018)1 <br />