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E BUILDING PERMIT APPLICATION <br /> NOV 12 2023 <br /> CITY OF EVERETT PERMIT SERVICES J <br /> EVERETT SUBMITTAL INSTRUCTIONS: See applicable submittal checklist for submittal requirements and nuriA9cgfFopigs r �.rsuigw, <br /> WASHINGTON then drop off completed application plus all required submittal documents to 3200 Cedar l8,t ht n oo �p Bbx. <br /> CONTACT INFORMATION: (P)425-257-8810 I(E)PermitServices@everettwa.gov I(W)ever rgdrytl$eSerVices <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 4919 EVERGREEN WAY PARCEL#: 00581900000101 <br /> crTr EVERETT STATE WA ZIP 98203 <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential):QFC#852 -STARBUCKS KIOSK <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision. Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME:KROGER CO./AHMED MOHAMED (PM) <br /> OWNER MAILING ADDRESS: STREET 3701 S NORFOLK ST#301 <br /> CITY SEATTLE STATE WA ZIP 98117 <br /> OWNER PHONE:206-622-9740 OWNER EMAIL: ahmed.mohamed@kroger.com <br /> CONTRACTOR COMPANY NAME:WOODMAN CONSTRUCTION, INC. <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED):WOODMC116706 CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 30105 <br /> CONTRACTOR ADDRESS: STREET 10910 117TH PL NE <br /> clr! KIRKLAND STATE WA ZIP 98033 <br /> CONTRACTOR PHONE:425-454-3621 CONTRACTOR EMAIL:sue@woodmanconstruction.com <br /> PRIMARY CONTACT: ❑OWNER ❑✓ CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE:425-454-3621 <br /> SUE S HAN G G UAN CONTACT EMAIL:sue@woodmanconstruction.com <br /> BUILDING INFORMATION <br /> VALUATION OF WORK:$60,000 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:M - Grocery Store <br /> PROPOSED USE OF BUILDING:Existing/ No Change <br /> HEAT SOURCE: ❑Gas ❑Electric ❑Other <br /> BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-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 ❑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 /> Install new Starbucks kiosk in formerly closed Starbucks space. Build non-bearing wall <br /> to create new storage room. New caseworks, finishes. Replace ceiling & lighting. <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 State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> Coa -- Digitally signed by Sue Shangguan PERMIT# <br /> Date:2023.11.02 16:43:54-07'00' 11/2/2023 ) 7 <br /> Owner/Authorized Agent Signature Date (Revised 4/21/2022) C/ �Cl <br />