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• <br /> NMI <br /> BUILDING PERMIT APPLICATION <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.govipermits -ZoN/e0 <br /> (Blue or Black ink Only Please) PROJECT SITE INFORMATION VV.,/ 1s4t. IY‘ <br /> PROJECT SITE ADDRESS: STREET (C,30(:). CV.6 VZ-;10..e67-(\1 CVn" PARCEL#: CX2)1;C37C,C)Ca) 17 co <br /> CITY 6--NitrtA VaA STATE L 11\ ZtP 93ZI3 <br /> SUITE/UNIT tc.,A FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential): C <br /> LEGAL DESCRIPTION for new construction: Short Piatisubdivision: Lot No.: (attach copy of long legal description) <br /> CONTACT'INFORMATION <br /> OWNER NAME: iY\ E. (‘..) <br /> OWNER MAILING ADDRESS: STREET /3/0 ectc 114-VC-=- <br /> CITy STATE tt.1(4- ZIP 9 <br /> OWNER PHONE: 4‘?-4) 7s-y-69632- OWNER EMAIL: H VsC-3,31frk <br /> CONTRACTOR COMPANY NAME: Lk,)4(jST- ( - <br /> WA STATE CONTRACTOR LICENSE#(1REQUIREICLANSre.DSS-3-S CITY OF EVERETT BUSINESS LICENSE CREQUIREDli Ser-Li/0 Ce <br /> CONTRACTOR ADDRESS: STREET <br /> A/L,C) " tk <br /> cirr vt 13 <br /> - -3- STATE <br /> CONTRACTOR PHONE: z, 2&. z6- 3i CONTRACTOR EMAIL: LC(.n1k <br /> PRIMARY CONTACT:y_QWNER LI CONTRACTOR LI OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE:( Z ) ) 6771:3 -- <br /> (\eN .1-‘c}6Er\ CONTACT EMAIL: fh • <br /> CA;ir‘ <br /> BUILDING INFORMATION <br /> VALUATION OF WORK: ASSOCIATED LAND USE PROJECT#(if applicable): <br /> (Valuation shall include the prevailing fair mark LI value of al labor,maierels,and equipment needed to complete the work.whether actually paid or not.) <br /> EXISTING USE OF BUILDING: voe <br /> PROPOSED USE OF BUILDING: V tic 5\--Noe <br /> HEAT SOURCE: 06as DElectric DOther <br /> BUILDING TYPE: OSFR OTownhouse ODuplex LIADU 0Multi-Family-#Units: IDCOmmercial DAccessory Structure <br /> TYPE OF PROJECT(check all that apply): ONew Construction DAddition DRemodel DRepair LIT.I. C:thange of Use <br /> DModular DPortable DRe-roof DExterior Alteration OTank(above ground) DAccessory Structure <br /> OFence over 7ft high DRackStorage OPool/Hot Tub OTank(above ground) [ Or: ,iNtv VI4c9Z-V\ <br /> DESCRIPTION OF WORK: <br /> --m-1> Pe )(vx elt_31.5crk <br /> CZ-LiSat- RSitiKri Pirri" Lit)9-13-C <br /> ACKNOWL6GEMENT 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 am authorized by the owner of this property to perform the work for which application is made. <br /> andi comp)/with the State Contractors Lew 18.27 RCW and 296.200A WAC. , <br /> / I City of Everett Official Use Only <br /> I I r.I/ PE17334.7_0 <br /> • \ <br /> l DLI, <br /> ownerrAut6orized Agent Signature Date ' (Revised 21812021) <br /> Z_ <br />