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OrETT 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 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: 1005 91ST PL SW PROPERTY TAX#: 00703500002100 <br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: AMPUDIA ERICK/ HANAOKA MIZUKI TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET 1005 91ST PL SW <br /> cmr EVERETT STATE WA ZIP 98204 <br /> OWNER PHONE: 206 832 5026 (OWNER EMAIL: bema.peace.care@gmail.com <br /> CONTRACTOR NAME: Self (Erick Ampudia/Mizuki Hanaoka) <br /> CONTRACTOR ADDRESS:.'✓ STREET 1005 91st PL SW <br /> CITY Everett STATE WA ZIP 98204 <br /> CONTRACTOR PHONE: 425-626-6425 CONTRACTOR EMAIL: bema.peace.care@gmail.com <br /> CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR p OTHER(Please Specify) DESIGNER <br /> CONTACT NAME: CONTACT PHONE: 425 877 7377 <br /> LUIS F. SIALER CONTACT EMAIL: sialerdesign@gmail.com <br /> BUILDING PERMIT APPLICATION C��ry►y� <br /> Existing Use of Building: R-3 �.OIut_.T" FAME ,:_y . -�: e': `. Contract Price of Work: $ u�-CJ`� <br /> Proposed Use of Building: R-3 AOUCCr ` M( cul 'ct614 c.? Heat Source: ❑Gas ❑Electric Other MINI SPLIT SYSTEM <br /> Building Type: ❑SFR-Detached FR-Attached ❑Duplex ❑Multi-Family-#of Units: ECommercial ❑Industrial <br /> Type of Project: ❑New ElAddition 2Remodel ❑Repair DTI. ❑Sign ❑Sprinkler ❑Demolition ❑Change of Use <br /> DESCRIPTION OF WORK: ,.1 .,-:--y,.` ..-11-•', k.16 A.Dot•-: 'r:-''1% t <br /> 528 SF OF EXISTING ATTACHED GARAGE TO BE CONVERT INTO LIVING SPACE AND ADD 570 SF OF NEW ADDITION <br /> ASSOCIATED BUILDING PERMIT#(if applicable). <br /> MECHANICAL PERMIT APPLICATION PLUMBING PERMIT APPLICATION <br /> Type of Project: _New 6/ Addn _Alteration Repair Type of Project: New )LAddn _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 /> A/C—Air Handling Units .p Heat Pump w5 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 j Water Heater Other: <br /> C Exhaust Fan A5, 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 Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PE <br /> Owner/Authorized AA ent Signature Date (Revised 9/23/2016) -I <br />