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i BUILtIING PERMIT APPLICATIO% <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 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 /> PRQIECT SITE ADDRESS! (d l t s„sEET A-VE PARCEL#: 004S I S V b g O 0 #O 2_ <br /> cm/ Evrd- T1 STATE WA- ZIP Ctt2.O( <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential): <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: 1SeV i t'\ LC) <br /> OWNER MAILING ADDRESS:tO1\STREET Ed warp( A'-€ <br /> crry J k STATE ZIP Q 2 0 <br /> OWNER PHONE: ZO(o- Ltt q - O OJ OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME: DeC-t SI vC• <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): 1la-ed ($(QOcf t. CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS:►'luicSsTREEr („0%-isk AVE Iv E 1- C c7 k <br /> crry \C7`a-- STATE Ltdei ZIP CI CC> <br /> CONTRACTOR PHONE: 2010 �J07► (o-1 1 CONTRACTOR EMAIL: -LA)co QAt pea.S • CoM <br /> PRIMARY CONTACT: ❑OWNER li CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 20(o — C0-1 I1 <br /> C t(\J — .LOu2S CONTACT EMAIL: _ Q}-I,l Q2.c.(C S. C O'M <br /> BUILDING INFORMATION <br /> VALUATION OF WORK:$ S-000 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: St vv.)Le_ --G yvl .1-( \ 4 7 Q <br /> PROPOSED USE OF BUILDING: �j yNci L �jr,f,yL l\1 (/Low'._( <br /> HEAT SOURCE: ❑Gas )IIElectric ❑Other <br /> BUILDING TYPE: IiISFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> TYPE OF PROJECT(check all that apply): ❑New Construction ❑Addition ❑Remodel M6epair ❑T.I. ❑Change of Use <br /> ❑Modular ❑Portable DRe-roof ❑Exterior Alteration ❑Tank(above ground) ❑Accessory Structure <br /> ❑Fence over 7ft high ❑RackStorage ❑Pool/Hot Tub DTank(above ground) I (Other: `r S O4-C- <br /> DESCRIPTION OF WORK: <br /> iS tk2 ema kr\S - 21 -vvi.oV& Q,tr r.Q N Lc`U S-Eel l r S <br /> -Pop-A c't.A <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.lam the owner,or lam 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 /> City of Everett Official Use Only <br /> CO—C29ZCC(A/Wa-- _/23 /2/ PERMIT# <br /> 017 <br /> Owner/Authorized Agent Signature Date (Revised 2/8/2021) <br /> /2_ <br />