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4 <br /> Imo <br /> BUILDING PERMIT APPLICATION <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 I(E)everetteps@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET /0‘1 /00 t'' 5r Cj Cc,/ PARCEL# &O y/3QO 30/ 'C)C) <br /> CITY E t_d_+ STATE \K/I l ZIP 9 o7 / <br /> SUITE/UNIT#: FLOOR#: L Z I t<' /ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential): <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: 9-o/0 Lot No.: .44 (attach copy of long legal description) <br /> tt CONTACT INFORMATION <br /> OWNER NAME: I US.,5T"C.t kA I\U r'L 1. <br /> OWNER MAILING ADDRESS: STREET ' 6(DX A <br /> CITY t— .Ck�r`�S�.} \I' STATE W zip CS 1 u, <br /> OWNER PHONE: IA ZJ 6 )(; (S)S5 I OWNER EMAIL:&1 S`,7/ f\ et)5/0/L1(C fJ 7%L06,0 <br /> CONTRACTOR COMPANY NAME: 0 i;{��f A `° cry Ct rr L C: r"\ �Y"11.C1� n✓1 <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED):go, 7((Sa J'(t�, CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 5 333 <br /> CONTRACTOR ADDRESS: STREET 1V() �2jQyk,! \2'—t <br /> CITY 'Acl, ; S U l \, STATE VIA'1 ZIP <..A,i : �`._. li <br /> CONTRACTOR PHONE: 41 �°-( -j 7�- hs' CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: SOWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: Lk Z _)- (p <br /> t'l+ CONTACT EMAIL: BL;StZ�11 <br /> tr� <br /> BUILDING INFORMATION <br /> VALUATION OF WORK: $ Z�C I00 0 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: . as Lyt✓lectric ['Other <br /> BUILDING TYPE: iSFR ❑Townhouse ODuplex ❑ADU EMulti-Family-#Units: ❑Commercial ❑Accessory Structure <br /> TYPE OF PROJECT(check all that apply): few Construction ❑Addition ❑Remodel ❑Repair ❑T.I. EChange of Use <br /> EModular ❑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: / err A,c, <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 l 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 /> City of Everett Official Use Only <br /> _ PERMIT# • ^ 2 0 <br /> Owner/Authorized A nt Signature Date (Revised 2/8/2021) <br /> F �� <br />