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Ar a <br /> imis <br /> LI BUILDING PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVE R E T T <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.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 17 2 ) ale V L.L) PARCEL#: <br /> cn' 4 STATE Li., 14 ZIP 9? 2. 7 Z— <br /> SUITE/UNIT#: f-- / FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential): 6() go), 4,.( SA i-e-_ <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: /,I a1/4.COP ( Le e 4 /4/1-8-OWNER MAILING ADDRESS: STREET /^/,� /6 7 6( /4/1-8- c SE <br /> CITY • /kS I "t .)-- STATE ZIPQ� �2-7 L <br /> OWNER PHONE: 41Z C 31 v- 3 V S 7 OWNER EMAIL: 14'i.(�t¢,eI f•j p/"it 1p , (`01.4",_ <br /> CONTRACTOR COMPANY NAME: RO let 5-t3 4AS l5 h Sj, • �-L C.- <br /> WA nn <br /> STATE CONTRACTOR LICENSE#(REQUIRED): K� C isY ^ L-!S �2 }`^o Gp.1$t 6 CY,C,LI. <br /> Ro?JSoe c->��3 VERETT BUSINESS LICENSE#(RE I ED): <br /> CONTRACTOR ADDRESS: STREET /(jj 3 c ea.,i No L-..._ IA)a--y A <br /> CITY a 4 -L_- h u� / STATE (I � ZIP / r 2- 77 <br /> CONTRACTOR PHONE: 3 60 - 31,0 <br /> -O j 2.- I CONTRACTOR EMAIL: tro tA,Ul,.,L c_ @��,,�;(, ea....-i <br /> PRIMARY CONTACT: 'OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: 1114 t , ' .p,,,e CONTACT PHONE: VI s--_ 3 I c j_ 3Vs7 <br /> / h- CONTACT EMAIL: ,14(4)v8j o, 6 6 6,- ,,,,, <br /> B DING INFORMATION 5,W' i A c2.S2 -co w <br /> VALUATION OF WOR $ / 5-i 00 ,�- ASSOCIATED LAND USE PROJECT#(if applicable): <br /> (Valuation shall include the prevail' ' market value of all labor,mated quipment needed to complete the work,whether actually paid or not.) <br /> EXISTING USE OF BUILDING: Kati,I <br /> PROPOSED USE OF BUILDING: <br /> HEAT SOURCE: rkt as ❑Electric ❑Other <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 NIT.l. ❑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 /> feerk7:74/1 f Rae/6 j , 04-tz'-F <br /> 6.2e--4-( C-,0Jci/7) <br /> ttj o 4 Wcure-Laux2 <br /> Pk!(e.-4- r,,..Gt. 'I�/ <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 un.- any circumstance.l 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 : :27 RCW and 296.200A WAC. <br /> (--L L-11- 2-3 City of Everett Official Use Only <br /> a ,o <br /> Owner/Authorized Agent 1. •---- �__ Date (Revised 2/8/2021) <br />