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BUILDING PER <br /> MIT APPLICATI• <br /> • <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT <br /> SUBMITTAL INSTRUCTIONS:See applicable submittal checklist for submittal requirements and number of copies required for review, <br /> WASHINGTON then drop off completed application plus all required submittal documents to 3200 Cedar Street 2nd Floor Intake Drop Box. <br /> CONTACT INFORMATION: (P)425.257.8810 I(E)everetteps@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 3i ` S /Tir( PARCEL#: a G, Q <br /> CITY U./(9 L STATE J4'4 A ZIP 98 ( <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable):) a <br /> TENANT/BUSINESS NAME(if non-residential): �,8E .'(PR n a .S� /17,'tuj rJ 7b,?,i 9,' <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: Pi /L / /1 ( ST Tp <br /> OWNER MAILING ADDRESS: STREET /8. / mQa 1c R / V s <br /> CITY ,E /� ERE7 STATE ��,J ZIP 0 <br /> OWNER PHONE: /2- " j 9�� OWNER EMAIL: S_TE5(3P19-'L,'P J/9/kO(3, ac)* <br /> CONTRACTOR COMPANY NAME: <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: ., <br /> y�j� E CONTACT PHONE: � t- 9 <br /> Pi/4 JF/ /1, 5T f CONTACT EMAIL: TTP(e 01.,ir ,'/(0), C‹) <br /> BUILDING INFORMATION <br /> VALUATION OF WORK:$ 50E1, do ASSOCIATED LAND USE PROJECT#(if applicable): <br /> (Valuation shall include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> EXISTING USE OF BUILDING: / , -?Q 4-C ET <br /> PROPOSED USE OF BUILDING: J/ <br /> HEAT SOURCE: ❑Gas ❑Electric ❑Other <br /> BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex LIADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> TYPE OF PROJECT(check all that apply): ❑New Construction ❑Addition ❑Remodel ❑Repair ❑T.I. ❑Change of Use <br /> ❑Modular ❑Portable ❑Re-roof ❑Exterior Alteration ❑Tank(above ground) ❑Accessory Structure <br /> ❑Fence over 7ft high ❑RackStorage ❑Pool/Hot Tub ❑Tank(above ground) ❑Other: <br /> DESCRIPTION OF WORK: <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 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 and 296.200A WAC. <br /> t �J�J City of Everett Official Use Only <br /> PITtft <br /> Owner/Authorized Agent 4nature Date (Revised 2/8/2021) <br /> y2— <br />