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$,~ ® • <br /> s j BUILDING PERMIT APPLICATION <br /> E�/ CITY OF EVERETT PERMIT SERVICES <br /> y E R E T T SUBMITTAL INSTRUCTIONS:See applicable submittal checklist for submittal requirements and number of copies required for review, <br /> wasHINGsoN then drop off completed application plus all required submittal documents to 3200 Cedar Street 2nd Floor Intake Drop Box. <br /> CONTACT INFORMATION:(P)425.257.88101(E).everetteps©everettwa.gov((W)everettwa.govlpermits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 2215 Merrill Creek PKWY PARCEL#: 28040200300300 <br /> ctrY Everett STATE WA Z1P 98203 <br /> SUITE!UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION(if applicable): <br /> TENANT/BUSINESS NAME(if non-residential): Crown Castle on behalf of Dish wireless <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: Crown Castle as Tower and Facility Owner <br /> OWNER MAILING ADDRESS: STREET 1505 Westlake Ave N,Suite 800 <br /> CITY Seattle STATE WA pip 98109 <br /> OWNER PHONE: (309)269-7254 OWNER EMAIL: Kate.Hanstrom.Contractor@crowncastle.com <br /> CONTRACTOR COMPANY NAME:TBD at Issuance <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE 21P <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR IE OTHER(Please Specify) Crown Castle on behalf of Dish <br /> CONTACT NAME: CONTACT PHONE:802-777-3358 <br /> Emilie Deschamps CONTACT EMAIL:Emilie@GMAnetworkservices.com <br /> BUILDING INFORMATION <br /> VALUATION OF WORK:$$25,000 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:U <br /> PROPOSED USE OF BUILDING:No change <br /> HEAT SOURCE: ❑Gas ❑Electric 00therN/A <br /> BUILDING TYPE: ❑SFR ❑Townhouse ODuplex ❑ADU DMulti-Family-#Units: ©Commercial ❑Accessory Structure <br /> TYPE OF PROJECT(check all that apply): ❑New Construction ❑Addition ❑Remodel ❑Repair ©T.I. ❑Change of Use <br /> ❑Modular ❑Portable Ole-roof ❑Exterior Alteration ❑Tank(above ground) ❑Accessory Structure <br /> OFence over 7ft high ❑RackStorage ❑Pool/Hot Tub ❑Tank(above ground) ©Other:Wireless equipment modification <br /> DESCRIPTION OF WORK:Minor Modification to Existing Wireless Facility. EFR Application. See Attached Project <br /> Description. <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 Slate Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> i..:....,. /A.... OtS' Z PERMIT#3/15/2022 zo 3-- 05Owner/Authorized Agent Signaltuir Date (Revised 2/8/2021) <br /> Y2_ <br />