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BLDING PERMIT APPLICATIA <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 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 fj D 2 �jd�1�,� �( . PARCEL#: O d y 121 I (��p gjc2 y o 0 <br /> STATE A, ZIP 'LQ1 <br /> SUITE/UNIT#: FLOOR#: (st* $°" ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential): V1,6,16\. YOCi?c S'Tv.1710 <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: l <br /> Y: GE g ZT D—Pl.Ipo1'CG� 13 Lot No.:/H a 2*'5 *Z47attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: Ve::.1 3 \AIDSG <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME: -1pj476 N141 <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED):f-X1 OmN C.u i1 - CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET //, <br /> CITY STATE ZIP e Y /2? <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: dd <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR XOTHER(Please Specify) Ac � G� <br /> CONTACT NAME: 1>a,n;4 \€— ' '( CONTACT PHONE: 2S 25 Z— 2153 <br /> oo IZ o1 ; CONTACT EMAIL: 41,AkAZ ? ZS t24,reA";•Vec-1.4e.e. - co vvk <br /> BUILDING INFORMATION <br /> VALUATION OF WORK: $ 1 D1 0 0 0 ASSOCIATED LAND USE PROJECT#(if applicable): <br /> (Valuation shall include the prevailing fair market value of at labor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> EXISTING USE OF BUILDING: /1 111.ejt N S <br /> PROPOSED USE OF BUILDING: VJvt.St N e.c 5 <br /> HEAT SOURCE: 210as ❑Electric ❑Other <br /> BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: 6ommercial ❑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 /> F�. t <br /> Li Fence over 7ft high ❑RackStorage ❑Pool/Hot Tub ElTank(above ground) ❑Other: <br /> DESCRIPTION OF WORK: <br /> -ro 1—o %-c6N> \ -I- JUN 2 8 2023 <br /> 7vAv .n‘Nc.- • I5-se_ -t N L--rFLCI Y QF EVERETT <br /> Permit Services <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 /> pgIT#,2) <br /> oco-aoo <br /> Owner/Authorized Agent Signature Date (Revised 4/21/2022) <br />