10110 19TH AVE SE I-104 2023-12-11

• • 2 BUILDING PERMIT APPLICATION D EcEINE CITY OF EVERETT PERMIT SERVICES EVERETT SUBMITTAL INSTRUCTIONS: See applicable submittal checklist for submittal requirements numb r- co i r d for rE i WASHINGTON then drop off completed application plus all required submittal documents to 320 ar St bun&lo�e Dropx/. CONTACT INFORMATION: (P)425-257-8810 I(E)PermitServices@everettwa.gov I( everettwa.gov/permits (Blue or Black Ink Only Please) PROJECT SITE INFORMATION CITY OF tvtKt I I PROJECT SITE ADDRESS: STREET 10110 19th Avenue—SGUthwesf"� PARCEL#: 28051900117UZ0UIt Services CITY Everett STATE WA ZIP 98208 SUITE/UNIT#: 1104 FLOOR#: 1 ADDITIONAL LOCATION INFORMATION (if applicable): TENANT/BUSINESS NAME(if non-residential):Mercy Housing iLEGAL DESCRIPTION for new construction: Short Plat/subdivision: Lot No. (attach copy of long legal description) CONTACT INFORMATION OWNER NAME: Family Tree & Lincoln LLLP OWNER MAILING ADDRESS: STREET 2505 Third AVE Ste 204 CITY Seattle STATE WA ZIP 98112 OWNER PHONE: OWNER EMAIL: CONTRACTOR COMPANY NAME: Interstate Restoration �-\;.;�%i�_ �'� i J :( 5- i K WA STATE CONTRACTOR LICENSE#(REQUIRED):€o2a4,66 - CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 55636 CONTRACTOR ADDRESS: STREET22342 68th Ave s CITY Kent STATE WA ZIP 98023 CONTRACTOR PHONE:36 `349-6579 CONTRACTOR EMAIL:Mike.Bergman@firstonsite.com PRIMARY CONTACT: ❑OWNER WI CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE:360-349-6579 Mike Bergman CONTACT EMAIL:mike.bergman@firstonsite.com BUILDING INFORMATION VALUATION OF WORK: $3000.00 ASSOCIATED LAND USE PROJECT#(if applicable): (Valuation shall include the prevailing fair market value of at labor,materials,and equipment needed to complete the work,whether actually paid or not.) EXISTING USE OF BUILDING:multi-Family PROPOSED USE OF BUILDING:Multi-Family HEAT SOURCE: ❑Gas ✓❑Electric ❑Other BUILDING TYPE: EISFR ❑Townhouse ❑Duplex ❑ADU ❑✓Multi-Family-#Units: ❑Commercial ❑Accessory Structure TYPE OF PROJECT(check all that apply): ❑New Construction ❑Addition ❑Remodel LRepair ❑IT.I. HChange of Use ❑Modular ❑Portable ❑Re-roof ❑Exterior Alteration ❑Tank(above ground) ❑Accessory Structure ❑Fence over 7ft high ❑RackStorage ❑Pool/Hot Tub ❑Tank(above ground) i lOther: DESCRIPTION OF WORK: Replace Insulation and Drywall in the listed unit Due to water loss. No alterations 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 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.I am the owner,or I am authorized by the owner of this property to perform the work for which application is made, and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only /7' 3/29/2023 PERMIT# Owner/Authorized Agent Signature Date (Revised 4/21/2022)