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0 PERMIT APPLICATI* <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 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br />(Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br />PROJECT SITE ADDRESS: 1605 SE Everett Mall Way, Everett WA 98208 <br />PROPERTY TAX #: 28051800405600 <br />LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description) <br />CONTACT INFORMATION <br />OWNER NAME: Wal-Mart Real Estate Business Trust TENANT NAME (If Commercial): Electrify America <br />OWNER MAILING ADDRESS: STREET 2001 SE 10th Street <br />CITY Bentonville STATE AR zip 72716 <br />OWNER PHONE: <br />OWNER EMAIL: <br />CONTRACTOR NAME: TBD 1;V4 U.-C 1 l <br />CONTRACTOR ADDRESS: STREET 2a 7.47 S Rax #,mik <br />CITY P <br />STATE O ZIP -7 2.6-2, <br />CONTRACTOR PHONE: S03 $ II r Sa3$ <br />1CONTRACTOR EMAIL: -'rl qw p <br />CONTRACTOR LICENSE #(REQUIRED): <br />CITY OF EVERETT BUSINESS LIC SE #(REQUIRED): <br />PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR P OTHER (Please Specify) Black & Veatch for Electrify America <br />CONTACT NAME: <br />Christina Suarez <br />CONTACT PHONE: 541.490.3080 <br />CONTACT EMAIL: suarezC bv.com <br />BUILDING PERMIT APPLICATION <br />Existing Use of Building: NA <br />lContract Price of Work: $ 100000.00 <br />Proposed Use of Building: NA <br />Heat Source. []Gas ❑Electric ❑Other <br />Building Type: ❑SFR-Detached ❑SFR-Attached ❑Duplex ❑Multi -Family-# of Units: ❑Commercial ❑Industrial <br />Type of Project: ❑New OAddition ❑Remodel ❑Repair ❑T.I. ❑Sign ❑Sprinkler ❑Demolition ❑Change of Use <br />DESCRIPTION OF WORK: <br />Installation of Electric Vehicle Charging Station in existing Wal-Mart parking lot. <br />ASSOCIATED BUILDING PERMIT # (if applicable): <br />MECHANICAL <br />PERMIT APPLICATION <br />PLUMBING PERMIT APPLICATION <br />Type of Project: <br />_New _ Addn _Alteration <br />_Repair <br />Type of Project: _New _Addn <br />_Alteration _Repair <br />#of <br />Fixtures <br />List of Fixtures <br />#of <br />Fixtures <br />List of Fixtures <br />#of <br />Fixtures <br />List of Fixtures <br />#of <br />Fixtures <br />List of Fixtures <br />A/C — Air Handling Units <br />Heat Pump <br />Toilet <br />Backflow Preventer (Inside Bldg) <br />Forced Air Systems <br />Unit Heater <br />Bathtub <br />Urinal <br />Gas Piping <br />Boiler <br />Lavatory (Wash Basin) <br />Drinking Fountain <br />Water Heater <br />Refrigeration <br />Shower <br />Floor Drain <br />Gas Fireplace <br />Wood Stove <br />Kitchen Sink & Disposal <br />Grease Trap <br />Gas Range <br />Ducting <br />Dishwasher <br />Roof Drains <br />Clothes Dryer Hookups <br />Other: <br />Clothes Washer <br />Medical Gas <br />Range Hood <br />Water Heater <br />Other: <br />Exhaust Fan <br />Sink (Service/Bar/Mop/etc.) <br />Other: <br />SPRINKLER <br />/ SUPPRESSION <br />SYSTEM <br />Chemical or Water <br />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 authoriz der airy 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 wit State Contraptors Law 18, 27 RCW and 296.200A WAC. <br />Owner uthorized Agent(Signature <br />City of Everett Official Use Only <br />PERMIT # <br />(Revised 912312016) <br />L <br />