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PERMIT 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 I FAX 425-257-8857 1(E)everetteps@everettwa.gov 1 www.everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: 2.4e23 G GI r-31..U1 Q 4s .e PROPERTY TAX#: <br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: 0(la,viLpj4o(-7(Ro\r)/5 1 % TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET Z2 C) V4'011.2(1 Kdl <br /> CITY La`C �..e().641 5 STATE ZIP q 2 $. <br /> OWNER PHONE: ZO(z, W 95c OWNER EMAIL: `Tai 61 2� rna Lc�WI <br /> CONTRACTOR NAME: 0wvt-ems <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> PRIMARY CONTACT: %OWNER 0 CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT` NAME: CONTACT PHONE: Z0 6 k; --4... 421.4/1.2R,(..- � j ci% <br /> 13r10%vl L-Q.w `lizd(19vi k1' CONTACT EMAIL: `C:\ices � 2w-7 <br /> BUILDING PERMIT APPLICATION <br /> Existing Use of Building: Re4g-e)1 4-fA I Contract Price of Work:$ 5co0 <br /> Proposed Use of Building: ..5'A 1"7.€. Heat Source: ❑Gas 4Electric ❑Other <br /> Building Type: ASFR-Detached ❑SFR-Attached ODuplex ❑Multi-Family-#of Units: ❑Commercial ❑Industrial <br /> Type of Project: ❑New ❑Addition Remodel PiRepair ❑T.I. ❑Sign ❑Sprinkler ❑Demolition ❑Change of Use <br /> DESCRIPTION OF WORK: S <br /> 1 e.-- Koo'- 1 ho ` ��?Y`rl Y''4d��I dC' t�41(0'� c'`,'t- 4�ts 4- 11/ '!e <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 #°f List of Fixtures List of Fixtures #of List of Fixtures #°f List of Fixtures <br /> Fixtures Fixtures Fixtures Fixtures <br /> A/C—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 I 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 property to perform the work for which application is made, <br /> and I comply with the State Contrac�, Law 18.27 RCW and 296.200A WAC. <br /> c-2----7 ,1 , (� � City of Everett Official Use Only <br /> `F f cg°' PERMF' t g 05-.0 _N� <br /> /V <br /> Owner/Authorized Agent Signature Date (Revised 9/23/2016) <br /> 4 <br />