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1 � <br /> BUILGiiJG 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)PermitServices@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET L! 3 Z (1 ( ' SC 5 t-- PARCEL#: <br /> CITY LJ CIZZ( STATE W A ZIP Ct 82-OS <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential): <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: 3ca 3 ) V t7.a-L.)3- <br /> �J <br /> OWNER MAILING ADDRESS: STREET 2_1 52 ( �b .M S i S A q p y <br /> CITY ��G QE TT STATE W A ZIP v 0 b <br /> OWNER PHONE: L!Z.j t4-1-( 't't5�3 OWNER EMAIL: V�nuj"-) e L rti4it_ . C�a►'''� <br /> CONTRACTOR COMPANY NAME: T t5C) 0(,J/v62., -S 60(1 "� <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 ❑OTHER(Please Specify) <br /> CONTACT NAME: J CONTACT PHONE: W Z S 1.� I t c 23 <br /> 1() �`i eef-Nri N CONTACT EMAIL: Ve_pk iy-1r1 e <br /> BUILDING INFORMATION <br /> VALUATION OF WORK:$ l ? k 3 i S 4'O,t-L'ASSOCIATED LAND USE PROJECT#(if applicable): <br /> (Valuation shall include the prevailing fair market lie of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> EXISTING USE OF BUILDING: / (2 i y I pC�J t Ali._ <br /> PROPOSED USE OF BUILDING: Kpp cT.u rJ <br /> HEAT SOURCE: ❑Gas 'lElectric ❑Other <br /> BUILDING TYPE: IFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> TYPE OF PROJECT(check all that apply): ❑New Construction 2rAddition ❑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 /> boo►�� L 7e. <br /> E <br /> JAN 21 2024 <br /> CITY OF EVERETT <br /> ACKNOWLEDGEMENT'I have reviewed this application and confirm the information contained herein is true and correct.Work done pursue flit with <br /> current federal,state,and local law. The granting of a permit only authorizes approved work and no deviations therefrom.Deviations must first e t rm 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 /> PERMIT# �7 . / <br /> 1�IL Z „`- 6( -0 <br /> Owner/Auth gent . ature Date (Revised 4/21/2022) <br />