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EALDING PERMIT APPLICA1N <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)everetteps@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION ? <br /> PROJECT SITE ADDRESS: STREET I V CI 1/i'C\ \c._ 1 1 �/ PARCEL#: 06/138/.3�7 /j00 <br /> CIrY k,vere. / STATE WON_ ZIP 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 /> � NC,OI CONTACT INFORMATION <br /> OWNER NAME: \)00\es (etreSc. I/'`pc- 1 <br /> OWNER MAILING ADDRESS: STREET/p?/? /—/Ot,{ f Q(�J , <br /> CITY �jvere-l-f' `1 STATE l� ZIP /i. 2c, <br /> OWNER PHONE: 4/?5 - (999_ 960 q OWNER EMAIL: e.LX 1956 6&-. Yy�� \ • c_prr‘ <br /> CONTRACTOR COMPANY NAME: l \ <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): '•t.c.& 3C 1C 7 CITY OF EVERETT BUSINESS LICENSE#(REQUIR D): <br /> CONTRACTOR ADDRESS: STREET , - A L,.t l— <br /> CITY 4—. r`^t- STATE ZIP 1 `e`.( <br /> CONTRACTOR PHONE: Zt C 2-7, .- �`�7 CONTRACTOR EMAIL: ate(-(li2 .c ----- <br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> T CONTACT EMAIL: �7n <br /> BUILDING INFORMATION <br /> VALUATION OF WORK: $ 50 OC2e) ASSOCIATED LAND USE PROJECT#(if applicable): <br /> (Valuation shall include the prevailing fair markret value of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> EXISTING USE OF BUILDING: <br /> PROPOSED USE OF BUILDING: <br /> HEAT SOURCE: ` Gas ❑Electric ❑Other <br /> BUILDING TYPE: XSFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> TYPE OF PROJECT(check all that apply): ❑New Construction ❑Addition li2Zemodel ❑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 /> bexA0 mevvk �D 61 e�� Lac e- ��`o,�oRS ) Lp.„50.AQ ��C cari'►cc� ( <br /> an- plurnlaton . Ltpc)r04e.. panel Xe ,,ram <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 mply with th State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> /� d-d2 / PEpc# <br /> W �l __0 0 <br /> 0 er/Auth i d Agent Signature ate (Revised 2/8/2021) <br />