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mil <br /> in EFaLDING PERMIT APPLICAISJN <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETTSUBMITTAL 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 0 Cr? it) <br /> . (,GIB I 1/1,0 . L LID"S'1 PARCEL#: <br /> CITY Mi"t /- STATE 0/A ZIP 1 Q 20 <br /> SUITE/UNIT#:Niti) 1404'l FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): <br /> ,r Q <br /> TENANT/BUSINESS NAME(if non-residential): r``�t/I nil <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: VV pA <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME: ,c(4,1 14,iiikt 0.L c \ <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): zo-\ <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: 0 OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: \� CONTACT PHONE: <br /> 1b A tt �Jklo- N ► It r)11., CONTACT EMAIL: <br /> BUILDING INFORMATION <br /> VALUATION OF WORK: $ ��t byO. �'� 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: 41 4 <br /> tv <br /> PROPOSED USE OF BUILDING: • <br /> HEAT SOURCE: ❑Gas ❑Electric Esther <br /> BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex ❑ADU ❑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 /> w1tA 1 I AMct O f-61/1V.kAA) <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 I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> Ci <br /> ty <br /> of Everett Official Use Only <br /> 6c..S <br /> P +.— CC <br /> Owner/Authorized Agent Signature Date (Revised 2/8/2021) (72 ) <br />