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NEN <br /> • • <br /> gm 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.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION /.y <br /> PROJECT SITE ADDRESS: sTREEr �� 9 ®� <br /> 0 S F Eiiwv /�q I/ 1L2 PARCEL#: <br /> CITY F v`Ale/4 STATE VA. ZIP 78W6(i <br /> SUITE/UNIT#: r- FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential): �q;1 " ���D lc <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdiv ion: <br /> Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: roe_ RA 100,_ <br /> OWNER MAILING ADDRESS: STREET to i (—Ili sr sr s <br /> cm' SI4 d Yt ill Lai STATE toA--_- /i0�9 J <br /> OWNER PHONE: 36 0-3G ZIP (y <br /> �O r &' (OWNER EMAIL: s (�e g-.cr/axy /L �YG�CONTRACTOR COMPANY NAME; I r V J VV HI D eirt ,v W <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): 1 t �l/�+ ICITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET <br /> CITY <br /> STATE ZIP <br /> CONTRACTOR PHONE: (CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: ElOWNER 0 CONTRACTOR 0 OTHER(Please Specify) Y <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <br /> BUILDING INFORMATION <br /> VALUATION OF WORK:$ �pV y0� OO <br /> (Valuation shall include the prevailing fair market of all labor,materials,and equipment!ASSOCIATED <br /> SSO eIded to <br /> complete AND USE*PROJECT er #lylpaid f or not.) <br /> EXISTING USE OF BUILDING: <br /> PROPOSED USE OF BUILDING: <br /> HEAT SOURCE: ❑Gas °Electric DOther <br /> BUILDING TYPE: ❑SFR °Townhouse ❑Duplex °ADU ❑Multi-Family-#Units: DCommercial DAccessory Structure <br /> TYPE OF PROJECT(check all that apply): °New Construction °Addition Xemodel °Repair DT.I. °Change of Use <br /> DModular °Portable °Re-roof ❑Exterior Alteration °Tank(above ground) DAccessory Structure <br /> ❑Fence over 7ft high DRackStorage °Pool/Hot Tub °Tank(above ground) °Other: <br /> DESCRIPTION OF WORK: <br /> CO1/l54`1u4� Of 1lit+P V 1 ar ko�— ke4VP, 4tv1dh la <br /> di ll 1ti vt q4Ce, <br /> I <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.lam 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 /> z„,67„_ <br /> City of Everett Official Use Only <br /> 1 3 a� , ,,,E,„„iTs22 , , , „, <br /> Jwne thorized Agent Signature Date Re I I <br /> (Revised 2M/2021) I <br />