3927 RUCKER AVE 3rd Floor 2022-04-08

.... n. BOLDING PERMIT APPLICAAWN CITY OF EVERETT PERMIT SERVICES EVERETT SUBMITTAL INSTRUCTIONS:See applicable submittal checklist for submittal requirements and number of copies required for review, WASHINGTON then drop off completed application plus all required submittal documents to 3200 Cedar Street 2nd Floor Intake Drop Box. CONTACT INFORMATION: (P)425.257.8810 I(E)everetteps@everettwa.gov I(W)everettwa.gov/permits (Blue or Black Ink Only Please) PROJECT SITE INFORMATION f PROJECT SITE ADDRESS: STREET 3927 Rucker Avenue PARCEL#: hcry Everett STATE WA zip 98201 i�r,'SUITE/UNIT#: FLOOR#: 3rd ADDITIONAL LOCATION INFORMATION (if applicable): TENANT/BUSINESS NAME(if non-residential):The Everett Clinic LEGAL DESCRIPTION for new construction: Short Plat/subdivision: Lot No.: (attach copy of long legal description) t CONTACT INFORMATION } OWNER NAME:The Everett Clinic *OWNER MAILING ADDRESS: STREET 3901 Hoyt Avenue 4 CITY Evertt STATE WA ZIP 98201 ;OWNER PHONE:425.210.8175 OWNER EMAIL: ken_mietzner@uhg.com !CONTRACTOR COMPANY NAME:Axiom Northwest Construction AWA STATE CONTRACTOR LICENSE#(REQUIRED):AXIOMNC920LJ CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 6' 4 & CONTRACTOR ADDRESS: STREET2232 Broadway#101 CITY Everett STATE WA Z1P 98201 "CONTRACTOR PHONE:425.903.4038 CONTRACTOR EMAIL:jennifer@axiomnw.com PRIMARY CONTACT: ❑OWNER ❑✓ CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE:425.750.6008 Jennifer@axiomnw.com CONTACT EMAIL:jennifer@axiomnw.com BUILDING INFORMATION VALUATION OF WORK:$34,794.38 ASSOCIATED LAND USE PROJECT#(if applicable): t(Valuation shall include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) *EXISTING USE OF BUILDING:office space in imaging department of healthcare facility ii PROPOSED USE OF BUILDING:office space in imaging department of healthcare facility HEAT SOURCE: ❑✓Gas ❑Electric ❑Other Ar Ci BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑✓Commercial ❑Accessory Structure 0. TYPE OF PROJECT(check all that apply): ❑New Construction ❑Addition ❑Remodel ❑Repair ETU. ❑Change of Use ❑Modular ❑Portable ❑Re-roof ❑Exterior Alteration ❑Tank(above ground) ❑Accessory Structure ❑Fence over 7ft high ❑RackStorage ❑Pool/Hot Tub Drank(above ground) ❑Other: it ;DESCRIPTION OF WORK: taking one existing office space and turning into two office spaces • 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 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 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, and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only / . PERMIT# i. 6.21.21 Fo TtOo — 05, Owner/Autho ed Agent Signature Date (Revised 2/8/2021) 4--