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4 <br /> s <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 1(E)PermitServices@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET-3 (r' 7 AJ SSoL✓ S"I PARCEL#: <br /> CITY Z':'e'f STATE d ZIP '� 2 I' I <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: h"\� �� I t�- <br /> OWNER MAILING ADDRESS: STREET ✓' U.5 'u' S t /CITY £,)Q(\ STATE ti ZIP 9 X ?J 1 <br /> OWNER PHONE: ( "LC) `3 5� �, Z Z/ OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME: icC k P,^ n ( � i`l --TT) C <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED):CI E 1 (,19 7 s't(A CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 5 ; L 4 7 <br /> CONTRACTOR ADDRESS: STREET S cd CDS l/ J 0`7 Z CITY rI fLki-J s I(e STATE W ZIP -7 iZ 7/I <br /> CONTRACTOR PHONE:(TZS) 3 j,j-- ,bO 'Z CONTRACTOR EMAIL: /VIC ( O/l`-I c c-�-)o,-\ 45n11-10< <br /> PRIMARY CONTACT: ❑OWNER ❑✓ CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: (4 z l 330 - ) Z <br /> f'`0`l( r(l k CONTACT EMAIL: M e, C:,/i ( <br /> BUILDING INFORMATION <br /> VALUATION OF WORK:$ J J, ^ ✓ 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: Sr- <br /> PROPOSED USE OF BUILDING: <br /> HEAT SOURCE: '[],Gas ❑Electric ❑Other <br /> BUILDING TYPE: SFR ❑Townhouse ❑Duplex EADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> TYPE OF PROJECT(check all that apply): ❑New Construction 0Addition2emodel ❑Repair ❑T.1. ❑Change of Use <br /> ❑Modular ❑Portable nfRe-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 /> I 'r� Q(L r cal Pe( i -s -g>r <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.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 /> / City of Everett Official Use Only /n <br /> b b�#v► ( ° /1t b! ZZ/ Z Z PERMIT# 12,D\nQ 0G2(0 <br /> Owner/Authoriied Agent Signature 1 Date (Revised 4/21/2022) <br />