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0 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 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br />OWNER NAME: O r' iz [' -L TENANT NAME (If Commercial): <br />OWNER MAILING ADDRESS: STREET <br />CITY - STATE ZIP <br />OWNER PHONE: 2040 2 2 S (S f 0 OWNER EMAIL: ,S1A 0V + <IG A P K CL 00, COwI <br />NAME: <br />ADDRESS: STREET <br />CITY <br />STATE ZIP <br />CONTRACTOR PHONE: ICONTRACTOR EMAIL: <br />CONTRACTOR LICENSE #(REQUIRED): CITY OF EVERETT BUSINESS LICENSE #(REQ IRED): <br />PRIMARY CONTACT: 19OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: CONTACT PHONE: 2 n 6 ZZ S 1 5(0 <br />P—O 076I2:t 1 J-1- ICONTACT EMAIL: s k o✓ - lckck (4D W a 14 o a . Co wn <br />Existing Use of Building: of A Contract Price of Work: $ <br />Proposed Use of Building: lHeat Source: ,'E9:6as ❑Electric ❑Other <br />Building Type: SFR-Detached WSFR-Attached ❑Duplex ❑Multi-Famil -# of Units: ❑Commercial ❑industrial <br />Type of Project: X(New ❑Addition ❑Remodel ❑Repair ❑T.1. ❑Sign []Sprinkler ❑Demolition ❑Chan a of Use <br />DESCRIPTION OF WORK:te <br />A41161 <br />[ASSOCIATED BUILDING PERMIT # (if applicable): <br />ACKNOWLEDGEMENT: l 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 t Stat Contractors Law 1 7 RC W and 296.200A WAC. <br />City of Everett Official Use Only <br />PER # <br />eH i Agent Signature Date (Revised 912312016) <br />t' <br />