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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 1(E)PermitServices@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET /�O5 'e C e�l`e,At /Mi PARCEL#: <br /> CITY ✓COY STATE ZIP ZO&� <br /> SUITE/UNIT#: FLOOR M ;L ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential): -z- LIYL ke_ <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: 16-vof&r PL11. L•G G F0 e ev7-e e 10 C . <br /> tj <br /> OWNER MAILING ADDRESS: STREET L L ����,1 �� 1,e U <br /> clrr lG U � STATE i�A zIP <br /> C <br /> • OWNER PHONE: M- 5-OT-6-777 OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME: e Y1,C' <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR 9OTHER(Please Specify) h <br /> CONTACT NAME: E 7,71 <br /> � ,V`�I ,� ^� CONTACT EMAIL: �O <br /> /V�wy <br /> dwna'cll wig R4 <br /> BUILDING INFORMATION <br /> VALUATION OF WORK:$ 5 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 ItElectfric ❑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 ❑PooUHot Tub ❑Tank(above ground) ❑Other: <br /> DESCRIPTION OF WORK: <br /> Nm3f -pr yy nar4 / IMUS i MY <br /> w <br /> wfo o riU-h o V1 I?a j?) <br /> 01- j <br /> ACKNOWLEDGEMENT:1 have reviewed this application and confirm the information contained herein is true and correct Work done pursu nt 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 fire 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 16.27 RCW and 296.200A WAC. <br /> City of Everett Offkial Use Only <br /> 0�o 23 PERMIT I1 t <br /> -i11 <br /> �, — �) � <br /> O n r/ thd&d Agent Signature Date (Revised 4121/1022) <br />