10614 21ST PL W 2023-09-15 - Laserfiche WebLink

BUILDING PERMIT APPLICATION CITY OF EVERETT PERMIT SERVICES EVERETT SUBMITTAL INSTRUCTIONS:See applicable submittal checklist for submittal requirements and number of copies required for review, WASHINGTON then drop off completed application plus all required submittal documents to 3200 Cedar Street 2nd Floor Intake Drop Box. CONTACT INFORMATION: (P)425-257-8810 1(E)PermitServices@everettwa.gov I(W)everettwa.gov/permits (Blue or Black Ink Only Please) PROJECT SITE INFORMATION PROJECT SITE ADDRESS: STREET 10614 21 ST PL W PARCEL#: crrr EVERETT STATE WA zlp 98204 SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): TENANT/BUSINESS NAME(if non-residential): LEGAL DESCRIPTION for new construction: Short PlaUsubdivision: Lot No.: (attach copy of long legal description) CONTACT INFORMATION OWNER NAME:YURIY SERGIYCHUK OWNER MAILING ADDRESS: STREET 10614 21 ST PL W cm, EVERETT STATE WA zip 98204 OWNER PHONE:(425)-626-7823 OWNER EMAIL: Yuriysipod@gmail.Com CONTRACTOR COMPANY NAME: OWN FK WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: PRIMARY CONTACT: 0 OWNER ❑CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE:(425)-626-7823 YU R I Y SERGIYCHUK CONTACT EMAIL:Yurlyslpod@gmall.Com BUILDING INFORMATION VALUATION OF WORK:$", 00-1,500 ASSOCIATED LAND USE PROJECT# if applicable): (Valuation shall include the prevailing fair market value of all labor,materials,and equipment needed to complete the vrork,whether actualy paid or not.) EXISTING USE OF BUILDING: PROPOSED USE OF BUILDING: HEAT SOURCE: ❑Gas ❑✓Electric ❑Other BUILDING TYPE: ❑✓SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure TYPE OF PROJECT(check all that apply): ❑New Construction ❑Addition ❑Remodel ❑Repair ❑T.I. ❑Change of Use ❑Modular ❑Portable ❑✓Re-roof ❑Exterior Alteration ❑Tank(above ground) ❑Accessory Structure ❑Fence over 7ft high ❑RackStorage ❑Pool/Hot Tub ❑Tank(above ground) ❑Other: DESCRIPTION OF WORK: Roof is currently very old and it needs to be replaced. ACKNOWLEDGEMENT:/have reviewed this application and confinn the information contained herein is true and correct. Work done pursuant to this permit must comply with 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 Building Official before being authorized under any circumstance.l am the owner,or l am authorized by the owner of this property to perform the work for which application is made, and l comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only 01-09-2023 PERMIT# �n,63011 _ 0 „ n Owner/Autho zed Agent Signature Date (Revised 9/21/2022) U"I