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DEMOLITION PERMIT APPLICATION <br /> EVERETT SUBMITTAL INSTRUCTIONS: <br /> OF EVERETT PERMIT SERVICES <br /> Drop off hard copy paper application&plan to 3200 Cedar Street 2nd Floor Intake Drop Box. <br /> WASHINGTON CONTACT INFORMATION:(P)425.267.8810 I(E)everetteps@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Back Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET I I Lar+ft VZ,-A PARCEL#: <br /> CITY L�vtY��"� ' w STATE ZIP <br /> SUITEIUNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: LL. <br /> OWNER MAILING ADDRESS: STREET 2, O 1 S L /7 <br /> CiTY ` �`��- STATE A- zip <br /> OWNER PHONE: 2rj Y� - "1 OWNER EMAIL: ma.jn t , (p <br /> CONTRACTOR CONTACT NAME: <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: ICONTRACTOR EMAIL: <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NA CONTACT PHONE: tJ<Z� -1 <br /> \� UCH -v CONTACT EMAIL: V_. C <br /> EMOLITION PERMIT INFORMATION <br /> VALUATION OF ORK:$ JASSOCIATED PERMIT/LAND USE PROJECT#(if applicable): <br /> (valuation shall include trV prevailing fair market value o abor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> BUILDING TYPE: n ouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial OAccessory Structure <br /> DESCRIPTION OF WORK: -T k Y-1 qOk t TeY1� 012:�UzY" <br /> #OF SQUARE FEET REMOVED: U <br /> #OF DWELLING UNITS REMOVED: <br /> HISTORIC STRUCTURE: ❑Yes o (Contact Planning Division to learn about additional requirements for historic structures(on Historic Registry or located in a Historic Overlay)). <br /> SHORELINE/FLOODPLAIN PROXIMITY: ❑YeS O(Contact Planning Division to learn about shoreline and ftoodplain requirements if structure being demolished is onrn either). <br /> EXISTING UNDERGROUND TANK: o Tank I ❑Yes-tank will stay in place-type: ❑Yes-tank to be removed-type: <br /> UNDERGROUND TANK SIZE: o ank ❑Under 10,000 gallons ❑l0,000 gallons or over <br /> PEDESTRIAN PROTECTION NEEDED: ❑Yes ONO (Required when demolition is inclose proximity to R.O.W.Include a pedestrian protection plan for review). <br /> CONSTRUCTION FENCING NEEDED: ❑Yes o (If yes,show the temporary construction fencing location on the required site plan). <br /> DUMPSTER IN R.O.W.NEEDED: ❑Yes No (If yes,apply for a separate Traffic Street Use Permit online at pw.everettwa.gov). <br /> TRAFFIC CONTROL PLAN NEEDED: ❑Yes MNo (Required when sidewalk,parking lane,or travel lane closure is needed. <br /> If yes,apply for a separate Traffic Street Use Permit online at pw.everettwa.gov). <br /> SEWER SERVICE CONNECTED TO BUILDING: ❑Yes UNo (If yes,a separate Utility Permit will be issued for side sewer cap off prior to demolition). <br /> WATER SERVICE CONNECTED TO BUILDING: ❑Yes LINO (If yes,cap at back side of meter prior to demolition and contact Utility Billing to stop billing). <br /> ELECTRICITY CONNECTED TO BUILDING: ❑Yes NNo(If yes,apply for separate Electrical Permit for disconnect and disconnect services prior to demolition). <br /> ABATEMENT ACKNOWLEDGMENTS: The applicant Is responsible for compliance with all local,state,and federal laws,codes,and regulations whether or not <br /> described herein.By checking the box next to each abatement type below,1,the ownenrapplicant,acknowledge my responsibility,agree to the terms and conditions of the <br /> requirements,and will abide by the requirements during construction. <br /> Asbestos Abatement:Required in line with Puget Sound Clean Air Agency(PSCAA)https://pseleanair.gov/.An Asbestos/Demolition Notification must be submitted <br /> to PSCAA before any asbestos removal or demolition begins and have the appropriate abatement report documentation on-site during construction. <br /> Lead Paint Abatement:Contact the Snohomish Health District(SHD)https://vmv.snohd.org/for applicable lead paint abatement requirements. <br /> Rodent Abatement:Proper rodent abatement shall be conducted prior to demolition. <br /> SITE LAN REQUIREMENTS:Submit 2 hard copies of site plan showing buildings to be demolished with permit application to Permit Intake Drop Box or attach <br /> electronic site plan with permit application if submitting electronically.Plans shall be in separate,compiled pdf,8.5x11 or 11x17 size.Naming convention: <br /> Address DemoPermitPlans. <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 1 comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PMkAIT# <br /> Owner/Authorized Agent Signature Date (Revised 21812021) <br />