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<br /> BUILDING PERMIT APPLICATION
<br /> EVERETT CITY OF EVERETT PERMIT SERVICES
<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.govlperrnits
<br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION
<br /> PROJECT SITE ADDRESS: STREET 1 G,i)A +(`) i tip'.k(,'y' Po)e., PARCEL#: 004351 51 0.} 0i '7 0 0
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<br /> _ CRY ;.--�1 I'' STAtE.: ,� ZIP CT(J...20 t
<br /> SIJITEtUNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION(if applicable):
<br /> TENANT/BUSINESS NAME(if non-residential):
<br /> LEGAL DESCRIPTION for new construction: Short Piat/subdivision: Lot No.: (attach copy of long legal description)
<br /> CONTACT INFORMATION .
<br /> OWNER NAME: t Z t' 1.1 [ \ Li, t',1 tj 5 t" J(k rt () R i e
<br /> OWNER MAILING ADDRESS: STREET 1 L1,, i 0 :; uk C'k e i'r f y't
<br /> crrY JE: Je f e. - yy
<br /> STATE W ��y ZIP C�st r,",�C) f
<br /> OWNER PHONE: 1/ F) `' '.30:;:i . fin(,) I (4-) OWNER EMAIL: - ' t`V`e. Y 1 k e,ki::i (1-. t_i 0 i SI C,,,,j : ri,,, °1_
<br /> CONTRACTOR COMPANY NAME: 12)C I) 14( I (f e). Cl
<br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): rt R:?E. CI I J 1 CiTY OF EVERETT BUSINESS LICENSE#(REQUIRED): 2 Li S 0 j
<br /> CONTRACTOR ADDRESS: STREET S t10'! ,)Li`I_t..11 ,..}' 5° \Iv
<br /> CITY i V)ll to I1 I_cL l i e l` if i•i C:.(' STATE \s,V /'L z,, 'I (}5' 6) `/.:3
<br /> CONTRACTOR PHONE: 43 E 7 7 1 — �?5 1 r\
<br /> CONTRACTOR EMAIL: O 1 .e) 1,1 ( r zt i")5 f t't,{t t1 I c h t,C: /I
<br /> PRIMARY CONTACT: [}OWNER ❑CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 7 / '> r� t t.
<br /> e,ri l 1 (- "e ' f i P‘ i'I _1,- CONTACT EMAIL: . j 'il Lr f(<e t`'; 4
<br /> `, . ` BUILDING INFORMATION
<br /> VALUATION OF WORK:$ gC 0 0 '.X.) )ASSOCIATED LAND USE PROJECT#(if applicable):
<br /> (Valuation shall include the prevailing fair market value plait tabor,materials,and equipment needed to complete the work,whetter actually paid or not)
<br /> EXISTING USE OF BUILDING: )i ) /l1<l/ ty S i dY'ri (` c;
<br /> PROPOSED USE OF BUILDING: Ili`i !'1.7C,r k., ;'i'S' ;(Li 11 I i
<br /> HEAT SOURCE: 1SaGas I3Electric ❑Other
<br /> BUILDING TYPE: QSFR DTownhouse DDuplex DAOU ['Multi-Family-#Units: ❑Commercial ❑Accessory Structure
<br /> TYPE OF PROJECT(check all that apply): ONew Construction QAddlllon ®Remodel DRepair ETA. DChange of Use
<br /> ['Modular ['Portable ®Re-roof gExtedor Alteration DTank(above ground) DAccessory Structure
<br /> ❑Fence over 7ft high DRackStorage ❑PoollHot Tub DTank(above ground) DOther:
<br /> DESCRIPTION OF WORK: ( (( / j i J 1 t_,
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<br /> ACKNOWLEDGEMENT::f have reviewed this application and confirm the Information contained heroin 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 f am authorzed by the owner of this property to perform the work for which application Is made,
<br /> and i cornOT with the State Contractors Law 18.27 RCW and 296,200A WAG.
<br /> ` Oily of Everett Official Use Only
<br /> PERMIT#
<br /> .1- -�.---- " , �-"` —. . 'L �:.2 f 6 z 1 0 6 -- D 03
<br /> "Owner/Authorized Agent Signature 7 Date (Revised 2/8/2021)
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