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0 PERMIT APPLICATIOP <br />BUILDING /MECHANICAL /PLUMBING /SIGN /SPRINKLER /DEMOLITION <br />EVERETT CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />WASHINGTON (P)425-257-8810 1 FAX425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br />(Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br />PROJECT SITE ADDRESS: 1321 Colby Avenue <br />PROPERTY TAX #: <br />LEGAL for new construction: Short Plattsubdivision Lot No. (attach copy of long legal description) <br />CONTACT INFORMATION <br />OWNER NAME: Providence Health & Services TENANT BUSINESS NAME (Commercial): <br />OWNER MAILING ADDRESS: STREET 105 W. 8th Avenue, Suite 7040 <br />cITv Spokane STATE WA zip 98204 <br />OWNER PHONE: <br />OWNER EMAIL: James.Grafton@providence.org <br />CONTRACTOR NAME: Providence Regional Medical Center Everett <br />CONTRACTOR ADDRESS: STREET 1321 Colby Avenue <br />CITY Everett STATE WA ZIP 98201 <br />CONTRACTOR PHONE: 425-261-3746 <br />CONTRACTOR EMAIL: Peter.Smeltz@providence.org <br />CONTRACTOR LICENSE #(REQUIRED): <br />CITY OF EVERETT BUSINESS LICENSE #(REQUIRED): <br />PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR El OTHER (Please Specify) Architect <br />CONTACT NAME: <br />Devi Saylor, AIA <br />CONTACT PHONE: 425-259-0868 <br />CONTACT EMAIL: devin@bnharch.com <br />BUILDING INFORMATION <br />Existing Use of Building: Hospital <br />Contract Price of Work: $ 25,000.00 <br />Proposed Use of Building: Hospital <br />Heat Source: OGas ❑Electric ❑Other <br />BUILDING USE: ❑SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi -Family- # Units: (]Commercial DAccessory Structure <br />Type of Project: ❑New ❑Addition R]Remodel []Repair ZT.I. ❑Sign ❑Sprinkler ❑Demolition ❑Change of Use <br />DESCRIPTION OF WORK: Interior Tenant Improvement remodel of an existing 2,973 SF clinic on the 2nd Floor <br />of the existing Hospital Building. <br />ASSOCIATED BUILDING PERMIT # if applicable): <br />MECHANICAL <br />PERMIT <br />APPLICATION <br />PLUMBING PERMIT <br />APPLICATION <br />Fixture <br />Count <br />List of Fixtures <br />Fixture <br />count <br />List <br />List of Fixtures <br />Count <br />List of Fixtures <br />Fixture <br />Count <br />List of Fixtures <br />A/C — Air Handling Units <br />Gas Piping <br />Backflow Preventer (Inside Bldg) <br />Shower, Tub, or Combo <br />Boiler <br />Gas Range <br />Clothes Washer <br />Sink -Commercial (3-comp,prep,floor) <br />Clothes Dryer <br />Heat Pump&Ductless <br />Dishwasher <br />Sink -Residential (kitchen,bath,bar) <br />Duct System (Remodel) <br />Refrigeration <br />Drinking Fountain <br />Sink -Utility, laundry, mop <br />Exhaust Fans (Residential) <br />Commercial Ventilatior <br />(Not Heat/AC system) <br />Floor Drain <br />Toilet <br />Exhaust Hood (Type 1) <br />Hose Bibb <br />Urinal <br />Exhaust Hood (Type II) <br />Water Heater <br />Interceptor -Grease <br />Waste/Water Piping Repair <br />Exhaust Hood (Residential) <br />Wood Stove <br />Interceptor-Sand/Oil <br />Water Service (behind meter) <br />Forced Air Systems <br />Other: <br />Medical Gas <br />Water Valves or Fixtures <br />Gas Fireplace/Insert/Log <br />I <br />Roof Drains <br />Water Heater <br />SPRINKLER I SUPPRESSION <br />SYSTEM <br />Sewage Ejector or Sump Pump <br />Other: <br />Water Suppression System <br />No. of Heads <br />Chemical Suppression System <br />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 1 comply with the State Contractors Law 18.27 RCW a;796.200A WAC. <br />�� City of Everett Official Use Only <br />C:LLIIN�- <br />PERMIT # <br />8-5-2019 I0 I <br />Owner/Authorized A nt Signat re Date (Revised 1011 12018) <br />Y <br />