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•LDING PERMIT APPLICA4N <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)PermitServices@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please)` PROJECT SITE INFORMATION ii <br /> PROJECT SITE ADDRESS: STREET 3(l®5 Rooket� Ave PARCEL <br /> S� l#: /113 00 7—OP" 0007 <br /> CITY E'V�e/1L STATE "V4 ZIP f 2 0/ <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential): Tito rt nt e <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: Rokby / 4t'<v <br /> OWNER MAILING ADDRESS: STREET 3yo f k''I1I AYE 5.f <br /> CITY /?en1714 STATE `✓4 ZIP 9;'d S"'7 <br /> OWNER PHONE: ti25--22i— 465-6 / OWNER EMAIL: kton kin a T 4G0�PLie 041(1. Co -" <br /> CONTRACTOR COMPANY NAME: L P San. e/'f Co, frUGAo L-4 C <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CCL pSoo,ir ICITY OF EVERETT BUSINESS LICENSE#(RE IRED): <br /> CONTRACTOR ADDRESS: STREET 2 II 9 Zd 5 i 3(j <br /> CITY 6 f c t /Q4/ STATE (4/0¢ ZIP 9YO2.4.. <br /> CONTRACTOR PHONE: 36a'2-37—)3or CONTRACTOR EMAIL:/&44h,CdJ LO✓7S17-6,claNr e y'ehvo. <br /> PRIMARY CONTACT: ❑OWNER 'CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 3 O - Z 3 7- Z 3 <br /> ilk 5446i/ars CONTACT EMAIL: kiSetna eeS 60n5 UGTGGq S`Gr/ Cc y„ <br /> BUILDING INFORMATION <br /> VALUATION OF WORK:$ 3o DOW 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: Fa i Faod Rci p 4lt (f` <br /> PROPOSED USE OF BUILDING: . 444e <br /> HEAT SOURCE: Gas ❑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 MT.!. ❑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) ❑Otther: <br /> DESCRIPTION OF WORK: p p 2 S4.ff: -,72 peen 1/r, W, ie/u, ct eq I4Odr 4a+7.1 SST k �o <br /> ye./ ev.i4efAki, wig!/ <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 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 <br /> �—�?- �Z PERMIT# {� �w <br /> Owner/Authorized Agent Signature Date (Revised 4/21/2t 02N�2) '!J' <br />