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moi <br /> une BUSING PERMIT APPLICATIOt <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 1(E)PermitServices@everettwa.gov I(W)etreretivva su ermits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION ' <br /> PROJECT SITE ADDRESS: STREET PAS 1,(J , CIA 51110 01(Z— PA EL#: r n ��yy L / <br /> CITY STATE - IP . GCV o <br /> SUITE/UNIT#, p 3 FLOOR#; ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential): LA f.& j--"D PI V I/e_ <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: W e .--r:I , O VL'.f` Co V,e„ 4 ° <br /> OWNER MAILING ADDRESS: STREET G 41IS- (-(-) ,5 ii't_' n (5) L( <br /> CITY e Ve fe -t-1- STATE ek) ZIP <br /> OWNER PHONE: L/2-5. EI- 3 2 OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME: CiDte c S ( (,-Q&h\I` 2 .j+V o.. -\ cD V-) <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED):GG RA N)IF O CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 57/0 CC <br /> CONTRACTOR ADDRESS: STREET glop d 5-02 tid �M H ' i A� <br /> CITY 4 Y'r5',S 4/CEO_ STATE CO g ZIP 78 a'2/ <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: E-/ -Zc, c�� �b �0 <br /> Mar+I r'1 1 C)4eVtA Q CONTACT EMAIL:ilia t"'Fi 1iL K7� Ci4s c tad es. itch Ur, ['61 VIA <br /> BUILDING� INFORMATION <br /> VALUATION OF WORK:$ 7'1isst044! t(f""�/�/ ASSOCIATED LAND USE PROJECT#(if applicable): <br /> (Valuation shall include the prevailing fair market 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: ❑SFR ❑Townhouse ❑Duplex DADU Multi-Family-#Units: ❑Commercial DAccessory Structure <br /> TYPE OF PROJECT(check all that apply): El New Construction DAddition ❑Remodelepair ❑T.I. ❑Change of Use <br /> DModular ❑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 /> 0,-�A nc yj" ' Is <br /> 4-ek <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 comply with the Sta tractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use <br /> Only <br /> ee 91 0 PE #2: v1 <br /> ner/Auth z (Date'ge atureRevised <br /> 4/21/2022) <br />