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MINE <br /> BODING PERMIT APPLICATJ <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)425.257.88101(E)everetteps@everettwa.gov 1(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 6107 Berkshire Dr. PARCEL#: 28050600401700 <br /> C,T Everett STATE WA ZIP 98203 <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential): Crown Castle on behalf of T-Mobile <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: SEC 06 TWP 28 RGE 05 Lot No: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME:City of Everett <br /> OWNER MAILING ADDRESS: STREET 3200 Cedar Street <br /> CITY Everett STATE WA ZIP 98201 <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME:TBD at Issuance 1\) tisn CAMSIY ,CAO i <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED):WIZEN t2 0156(O CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 3 3$(Ol <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ✓❑OTHER(Please Specify) Crown Castle on behalf of T-Mobile <br /> CONTACT NAME: CONTACT PHONE:425_269-5561 <br /> Renata Fayten CONTACT EMAIL:renatasoffice@gmail.com <br /> BUILDING INFORMATION <br /> VALUATION OF WORK:$$25,000 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:U <br /> PROPOSED USE OF BUILDING:NO change <br /> HEAT SOURCE: ❑Gas ❑Electric ❑OtherN/A <br /> BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑✓Commercial ElAccessory 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:Wireless equipment modification <br /> DESCRIPTION OF WORK: <br /> T-Mobile is proposing to modify its existing wireless facility by replacing (3)Antennas with <br /> (6) new antennas; (3) Radios with (3) new Radios; (3)TMAs with (3) new TMAs, (1) COVP <br /> with (2) Pendants and install (2) Hybrid Trunks on an existing tower. As well as replace (2) <br /> existing cabinets with (2) new cabinets within the existing leased ground space. <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 /> PERMIT# ^ !De ® /y <br /> Renata Fayten o'9'm'rowReaamFa " L ( `� <br /> Date:2021.08.0815:33:3T-0T00' 08/09/21 <br /> Owner/Authorized Agent Signature Date (Revised 2/8/2021) <br /> /z- <br />