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9 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 />(Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br />PROJECT SITE ADDRESS: 5107 23rd Ave W <br />I PROPERTY TAX #: 00669800000400 <br />LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description) <br />CONTACT INFORMATION <br />OWNER NAME: Albert Dahl TENANT NAME (If Commercial): <br />OWNER MAILING ADDRESS: STREET 5107 23rd Ave W <br />crry Everett STATE WA zip 98203 <br />OWNER PHONE: 425-239-3811 <br />OWNER EMAIL: albert.dahl@gmail.com <br />CONTRACTOR NAME: Island Gas Piping & Stove Installs, LLC <br />CONTRACTOR ADDRESS: STREET 4821 REINDEER RD <br />cnr Freeland STATE WA ZIP 98249 <br />CONTRACTOR PHONE: 360-929-1912 <br />1CONTRACTOR EMAIL: Aaron@lslandGasPiping.com <br />CONTRACTOR LICENSE #(REQUIRED): ISLANGP830D <br />ICITY OF EVERETT BUSINESS LICENSE #(REQUIRED) <br />PRIMARY CONTACT: OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />Albert Dahl <br />CONTACT PHONE: 425-239-3811 <br />CONTACT EMAIL: albert.dahl ail.com <br />BUILDINGPERMIT APPLICATION <br />Existing Use of Building: SFR <br />lContract Price of Wo , g 800 estimated <br />Proposed Use of Building: SFR <br />Heat Source: ❑Ga ❑Electric Other <br />Building Type: OSFR-Detached ❑SFR-Attached ❑Du lex ❑Multi -Family-# of Units: Commercial ❑Industrial <br />Type of Project: ❑New ❑Addition ❑Remodel ORepair 13T.I. ❑Sin ❑Sprinkler ❑Demolition ❑Chan a of Use <br />DESCRIPTION OF WORK: <br />Install Gas Piping <br />ASSOCIATED BUILDING PERMIT # if applicable): <br />IECHANICAL PERMIT APPLICATION ` <br />PLUMBING PERMIT APPLICATION " <br />Type of Project: _New AddnAlteration _Repair <br />Type of Project: _New _Addn _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 />INo. of Heads <br />iO1KEDGEMENT: 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 />iffederal, 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 />g Official before being authorized under any circumstance. 1 am the owner, or I am authorized by the owner of this property to perform the work for which application is made, <br />comply with the State Contractors Law 18.27 RCW d 296.200A WAC. <br />City of Everett Official Use Only <br />�> � PERMIT # O <br />.� S \ <br />Authorized Agent Signature ate (Revised 912312016) <br />