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LI BUILDING PERMIT APPLICAAN <br /> CITY OF EVERETT PERMIT SERVICES Akm.k . <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)PermitServices@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 3S DC) Ri CAi_4'1:.0, Ave PARCEL#: Dai{. 3g j DS'/i-0-2_ • <br /> E..I012.c`TT CITY STATE V V! 1- ZIP ' O 1 , <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: 7JS O (2.00(Z.,Ey E A [!, ` .LC— <br /> OWNERMAILINGADDRESS: STREET •CZ x ' O'9L.f- <br /> CITY \A3 O®I.•' ',ley t t f STATE 1/,� -- ZIP �V 3. <br /> OWNER PHONE: • 1� �{ /� ` <br /> �(�`S. ��. DO rU�" OWNER EMAIL:. I�j�I5,�2�j0�(I�CQ C��pL�.�, L(f�,t <br /> CONTRACTOR COMPANY NAME: —~ \c(jc ``� . `CQ 13 b �j <br /> WA STATE CONTRACTOR LICENSE#(REQUIREI L,.g CITY OF EVERETT BUSINESS LICENSE#(REQUIRED):(a L..'� <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: LWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> C 1:2( <br /> NTACT NAME: `n CONTACT PHONE: Li- �r��,o� C�9 <br /> Sm \L Y `�� Vy�T CONTACT EMAIL: �1 SYl(�a; 1»S,PO Q �t3.ThrAl cow <br /> BUILDING INFORMATION <br /> VALUATION OF WORK: $20,000 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: S Fg.. <br /> PROPOSED USE OF BUILDING: AD\..1 "}- Sc e. <br /> HEAT SOURCE: ❑Gas XElectric ❑Other <br /> BUILDING TYPEL FR ❑Townhouse ❑Duplex NADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> TYPE OF PROJECT(check all that apply): ElNew Construction ❑Addition CPZ.temodel ❑Repair ❑T.I. ❑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 /> AIR Ol l�',�",. �` '��i✓ e1/4- 01111.� ( NOV-12/VVA <br /> \ a ,'ov1 <br /> CILAX0 VV.-124kt ,cc—YV•N\ Me)< U." u -- • <br /> . <br /> ACKNOWLEDGEMENT:I have reviewed this applicati 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 rmit Qnly authorizes approved work and no deviations therefrom.Deviations must first be authorized in writing from the <br /> Building Official before being authorized under any 'rc stance.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 S e Contractors 1 W and 296.2 WAC. <br /> City of Everett Official Use Only <br /> il <br /> " i) ; 2oz� . \+122og -.8aOwner/Authogna ure De (Revised 4/21/2022) <br /> 1 <br />